Provider Demographics
NPI:1629057179
Name:LICON, OCTAVIO (MD)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIO
Middle Name:
Last Name:LICON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OCTAVIO
Other - Middle Name:P
Other - Last Name:LICON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10410 VISTA DEL SOL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7919
Mailing Address - Country:US
Mailing Address - Phone:915-592-3323
Mailing Address - Fax:915-593-8571
Practice Address - Street 1:10410 VISTA DEL SOL DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7919
Practice Address - Country:US
Practice Address - Phone:915-592-3323
Practice Address - Fax:915-593-8571
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-269207X00000X, 207XS0106X
TXF2773207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000EN585Medicaid
NM0000Y3758Medicaid
B24377Medicare UPIN
NM0000Y3758Medicaid