Provider Demographics
NPI:1336248863
Name:ICO, ROBERTO HWANG (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:HWANG
Last Name:ICO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5715 83RD LN
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-4631
Mailing Address - Country:US
Mailing Address - Phone:806-794-5329
Mailing Address - Fax:
Practice Address - Street 1:4601 S LOOP 289
Practice Address - Street 2:11
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2208
Practice Address - Country:US
Practice Address - Phone:806-792-7200
Practice Address - Fax:806-792-7225
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10358142251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8E0199Medicare PIN