Provider Demographics
NPI:1689842445
Name:JOHN A ICETON MD PA
Entity Type:Organization
Organization Name:JOHN A ICETON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ICETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-983-5178
Mailing Address - Street 1:2927 PARK PLAZA LN
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-5516
Mailing Address - Country:US
Mailing Address - Phone:409-983-5178
Mailing Address - Fax:
Practice Address - Street 1:2927 PARK PLAZA LN
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-5516
Practice Address - Country:US
Practice Address - Phone:409-983-5178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6857207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H6857OtherMEDICAL LICENSE
TX0978157-01Medicaid
TX0978157-01Medicaid
00D07WMedicare PIN
TX0978157-01Medicaid
H6857OtherMEDICAL LICENSE