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NPI Code Detail

MEDICARE: ICONIQ SPINE & ORTHOPAEDIC CENTER PLLC

MEDICARE: ICONIQ SPINE & ORTHOPAEDIC CENTER PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12081P2900XPain Medicine (Physical Medicine & Rehabilitation) Physician
2332B00000XDurable Medical Equipment & Medical Supplies
3208VP0014XInterventional Pain Medicine Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11780936971OTHERTXCASH

General Provider Information

NPI Number : 1578279238
Entity Type Code : Organization
Provider Name (Legal Business Name) : ICONIQ SPINE & ORTHOPAEDIC CENTER PLLC
Provider Business Mailing Address
First Line : 4441 W AIRPORT FWY STE 215
Second Line :
City : IRVING
State : TX
Zip : 75062-5959
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4441 W AIRPORT FWY STE 215
Second Line :
City : IRVING
State : TX
Zip : 75062-5959
Country : US
Telephone Number : 469-444-7246
Fax Number : 469-440-2667
Authorized Official
Title or Position : CEO
Name : TRUNG HA
Credential : MD
Telephone Number : 469-444-7246
Provider Enumeration Date : 01/26/2023
Last Update Date : 05/09/2024

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Directions to “ICONIQ SPINE & ORTHOPAEDIC CENTER PLLC ” Practice Location

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