Provider Demographics
NPI:1174643845
Name:LICKENBROCK, KEVIN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:LICKENBROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 ALBANY CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-4733
Mailing Address - Country:US
Mailing Address - Phone:314-961-4098
Mailing Address - Fax:
Practice Address - Street 1:2900 LEMAY FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-3900
Practice Address - Country:US
Practice Address - Phone:314-543-5294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE43813Medicare UPIN