Basic Information
Provider Information | |||||||||
NPI: | 1972689644 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LICON | ||||||||
FirstName: | CARLOS | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3750 COMMERCIAL AVE | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782213117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2103343700 | ||||||||
FaxNumber: | 2109220162 | ||||||||
Practice Location | |||||||||
Address1: | 3750 COMMERCIAL AVE | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782213117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2103343760 | ||||||||
FaxNumber: | 2109236355 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/27/2006 | ||||||||
LastUpdateDate: | 12/08/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M4290 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | BL9981184 | 01 | TX | DEA REGISTRATION | OTHER | 184983801 | 05 | TX |   | MEDICAID | X0148767 | 01 | TX | DPS | OTHER | 8G8247 | 01 | TX | BCBS | OTHER | 94846 | 01 | TX | CARELINK | OTHER |