Provider Demographics
NPI:1114218559
Name:JESSE J LICUANAN MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JESSE J LICUANAN MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LICUANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-531-0377
Mailing Address - Street 1:8251 LA PALMA AVE
Mailing Address - Street 2:SUITE 434
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3205
Mailing Address - Country:US
Mailing Address - Phone:562-531-0377
Mailing Address - Fax:562-531-1724
Practice Address - Street 1:3300 E SOUTH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90805-4549
Practice Address - Country:US
Practice Address - Phone:562-531-0377
Practice Address - Fax:562-531-1724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty