MEDICARE: JOHN A. ICETON M.D.

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
1	174400000X	Specialist	H6857	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H6857	OTHER	TX	MEDICAL LICENSE

General Provider Information

NPI Number	:	1770583858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN A. ICETON M.D.

Provider Business Mailing Address
First Line	:	2927 PARK PLAZA LN
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-5516
Country	:	US
Telephone Number	:	409-983-5178
Fax Number	:	409-983-6078

Provider Business Practice Location Address
First Line	:	2927 PARK PLAZA LN
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-5516
Country	:	US
Telephone Number	:	409-983-5178
Fax Number	:	409-983-6078

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	03/07/2023

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Directions to “ JOHN A. ICETON M.D.” Practice Location

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