Provider Demographics
NPI:1497913057
Name:JESUS L. LICUANAN, M.D. INC
Entity Type:Organization
Organization Name:JESUS L. LICUANAN, M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:L
Authorized Official - Last Name:LICUANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-521-1700
Mailing Address - Street 1:6131 ORANGETHORPE AVE
Mailing Address - Street 2:# 215
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-1315
Mailing Address - Country:US
Mailing Address - Phone:714-521-1700
Mailing Address - Fax:714-521-1003
Practice Address - Street 1:6131 ORANGETHORPE AVE
Practice Address - Street 2:# 215
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-1315
Practice Address - Country:US
Practice Address - Phone:714-521-1700
Practice Address - Fax:714-521-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAQ154OtherP-TAN
CA00A423000OtherBLUE SHIELD OF CALIFORNIA
CAA42300Medicaid
CABL0440519OtherDEA
CA00A423000OtherBLUE SHIELD OF CALIFORNIA
CA7568117Medicare PIN