Provider Demographics
NPI:1609873538
Name:LICANDRO, JIM PAUL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:PAUL
Last Name:LICANDRO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:PAUL
Other - Last Name:LICANDRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:5261 BOULDER DR APT D
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-7823
Mailing Address - Country:US
Mailing Address - Phone:563-340-4387
Mailing Address - Fax:563-424-7234
Practice Address - Street 1:405 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IA
Practice Address - Zip Code:52756
Practice Address - Country:US
Practice Address - Phone:832-425-7457
Practice Address - Fax:563-285-5446
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-07-22
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
IA00705213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1197210Medicaid
IAU75668Medicare UPIN
IA06737Medicare PIN
IA1197210Medicaid
IA06737Medicare ID - Type UnspecifiedMEDICARE