1609873538 NPI number — DR. JIM PAUL LICANDRO DPM

Table of content: DR. JIM PAUL LICANDRO DPM (NPI 1609873538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609873538 NPI number — DR. JIM PAUL LICANDRO DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LICANDRO
Provider First Name:
JIM
Provider Middle Name:
PAUL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LICANDRO
Provider Other First Name:
JAMES
Provider Other Middle Name:
PAUL
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1609873538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/21/2006
NPI Reactivation Date:
03/29/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5261 BOULDER DR APT D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50265-7823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-340-4387
Provider Business Mailing Address Fax Number:
563-424-7234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 WOODLAWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG GROVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-425-7457
Provider Business Practice Location Address Fax Number:
563-285-5446
Provider Enumeration Date:
07/07/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  00705 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1197210 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".