Provider Demographics
NPI:1407829641
Name:LICCIARDONE, JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:LICCIARDONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNTHSC DEPT. OF QUALITY MANAGEMENT
Mailing Address - Street 2:3500 CAMP BOWIE BLVD., EAD 324
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107
Mailing Address - Country:US
Mailing Address - Phone:817-735-0170
Mailing Address - Fax:817-735-0111
Practice Address - Street 1:UNTHSC PATIENT CARE CENTER
Practice Address - Street 2:999 MONTGOMERY
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-735-2235
Practice Address - Fax:817-735-2480
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH3103204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE33306Medicare UPIN
TX86E318Medicare ID - Type Unspecified