Healthcare Provider Details

I. General information

NPI: 1457463960
Provider Name (Legal Business Name): RAMIRO ICAZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N MAIN ST
SIKESTON MO
63801
US

IV. Provider business mailing address

430 WEST INDEPENDENCE STREET
JACKSON MO
63755
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-6001
  • Fax: 573-472-6006
Mailing address:
  • Phone: 573-243-0750
  • Fax: 813-891-9066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMDR7D79
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: