Provider Demographics
NPI:1033459581
Name:GUSTAVO C LICEA MDPA
Entity Type:Organization
Organization Name:GUSTAVO C LICEA MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:C
Authorized Official - Last Name:LICEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-664-9771
Mailing Address - Street 1:PO BOX 720162
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-0162
Mailing Address - Country:US
Mailing Address - Phone:956-664-9771
Mailing Address - Fax:956-664-9773
Practice Address - Street 1:2010 S CYNTHIA ST
Practice Address - Street 2:STE 101
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1386
Practice Address - Country:US
Practice Address - Phone:956-664-9771
Practice Address - Fax:956-664-9773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty