Healthcare Provider Details

I. General information

NPI: 1891054573
Provider Name (Legal Business Name): EDUARDO ICAZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 N KENDALL DR STE 410W
MIAMI FL
33176-2127
US

IV. Provider business mailing address

PO BOX 198054
ATLANTA GA
30384-8054
US

V. Phone/Fax

Practice location:
  • Phone: 786-871-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME157395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: