Healthcare Provider Details

I. General information

NPI: 1780753251
Provider Name (Legal Business Name): HOMERO SICANGCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S #105-B
ST AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

2950 MONTILLA DR
JACKSONVILLE FL
32246-5526
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-8906
  • Fax: 904-461-8907
Mailing address:
  • Phone: 904-461-8906
  • Fax: 904-461-8907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME71363
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: