Basic Information
| Provider Information | |||||||||
| NPI: | 1407829641 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LICCIARDONE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNTHSC DEPT. OF QUALITY MANAGEMENT | ||||||||
| Address2: | 3500 CAMP BOWIE BLVD., EAD 324 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177350170 | ||||||||
| FaxNumber: | 8177350111 | ||||||||
| Practice Location | |||||||||
| Address1: | UNTHSC PATIENT CARE CENTER | ||||||||
| Address2: | 999 MONTGOMERY | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177352235 | ||||||||
| FaxNumber: | 8177352480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | H3103 | TX | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
No ID Information.