Healthcare Provider Details

I. General information

NPI: 1922539055
Provider Name (Legal Business Name): DAVID OMAR HENRIQUEZ TICAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N FAIRBANKS CT STE 2-458
CHICAGO IL
60611-3013
US

IV. Provider business mailing address

1 BAYLOR PLZ MC 315
HOUSTON TX
77030-3411
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-3211
  • Fax: 312-503-8259
Mailing address:
  • Phone: 713-798-5490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036164840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: