Basic Information
| Provider Information | |||||||||
| NPI: | 1457463960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ICAZA | ||||||||
| FirstName: | RAMIRO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 WEST INDEPENDENCE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732430750 | ||||||||
| FaxNumber: | 8138919066 | ||||||||
| Practice Location | |||||||||
| Address1: | 1008 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734726001 | ||||||||
| FaxNumber: | 5734726006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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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 | 207Q00000X | MDR7D79 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000094200 | 01 | MO | MEDICARE ID KIES PERSONAL | OTHER | 202995807 | 05 | MO | MEDICAID |