Provider Demographics
NPI:1134449960
Name:OCTAVIO LICON, M.D. P.A.
Entity type:Organization
Organization Name:OCTAVIO LICON, M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OCTAVIO
Authorized Official - Middle Name:
Authorized Official - Last Name:LICON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-592-3323
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
Practice Address - Country:US
Practice Address - Phone:915-592-3323
Practice Address - Fax:915-593-8571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2773207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty