Provider Demographics
NPI:1497703193
Name:ICARRO, ROBERTO M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:M
Last Name:ICARRO
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 1:1743 WATSON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3633
Mailing Address - Country:US
Mailing Address - Phone:478-328-2122
Mailing Address - Fax:478-929-2242
Practice Address - Street 1:1743 WATSON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3633
Practice Address - Country:US
Practice Address - Phone:478-328-2122
Practice Address - Fax:478-929-2242
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051049207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000944633CMedicaid
GA11SCFKXMedicare PIN
H57555Medicare UPIN