Healthcare Provider Details

I. General information

NPI: 1114928066
Provider Name (Legal Business Name): ROMEO GONZAGA ICASIANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 SO 5TH ST
MONTROSE CO
81401-5716
US

IV. Provider business mailing address

947 SO 5TH ST
MONTROSE CO
81401-5716
US

V. Phone/Fax

Practice location:
  • Phone: 870-249-2421
  • Fax: 970-249-8897
Mailing address:
  • Phone: 870-249-2421
  • Fax: 970-249-8897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37326
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: