Provider Demographics
NPI:1134121940
Name:ICAZA, EDWARD EARL (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:EARL
Last Name:ICAZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:E
Other - Last Name:ICAZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5801 OAKBEND TRL STE 270
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3922
Mailing Address - Country:US
Mailing Address - Phone:817-615-9496
Mailing Address - Fax:855-576-4158
Practice Address - Street 1:5801 OAKBEND TRL STE 270
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3922
Practice Address - Country:US
Practice Address - Phone:817-615-9496
Practice Address - Fax:855-576-4158
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK265672084N0400X
TXK98092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7491118OtherAETNA
TX72JAOtherBCBS
H12083Medicare UPIN
TX00689TMedicare PIN