Healthcare Provider Details

I. General information

NPI: 1629057179
Provider Name (Legal Business Name): OCTAVIO LICON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: OCTAVIO P LICON M.D.

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10410 VISTA DEL SOL DR
EL PASO TX
79925-7919
US

IV. Provider business mailing address

10410 VISTA DEL SOL DR
EL PASO TX
79925-7919
US

V. Phone/Fax

Practice location:
  • Phone: 915-592-3323
  • Fax: 915-593-8571
Mailing address:
  • Phone: 915-592-3323
  • Fax: 915-593-8571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number86-269
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberF2773
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberF2773
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number86-269
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: