Provider Demographics
NPI:1457463960
Name:ICAZA, RAMIRO (MD)
Entity Type:Individual
Prefix:DR
First Name:RAMIRO
Middle Name:
Last Name:ICAZA
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 1:430 WEST INDEPENDENCE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755
Mailing Address - Country:US
Mailing Address - Phone:573-243-0750
Mailing Address - Fax:813-891-9066
Practice Address - Street 1:1008 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801
Practice Address - Country:US
Practice Address - Phone:573-472-6001
Practice Address - Fax:573-472-6006
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR7D79207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000094200OtherMEDICARE ID KIES PERSONAL
MO202995807Medicaid
MO001011843Medicare PIN
A11870Medicare UPIN
MO263914Medicare Oscar/Certification