Healthcare Provider Details

I. General information

NPI: 1134121940
Provider Name (Legal Business Name): EDWARD EARL ICAZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDWARD E ICAZA MD

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 OAKBEND TRL STE 270
FORT WORTH TX
76132-3922
US

IV. Provider business mailing address

5801 OAKBEND TRL STE 270
FORT WORTH TX
76132-3922
US

V. Phone/Fax

Practice location:
  • Phone: 817-615-9496
  • Fax: 855-576-4158
Mailing address:
  • Phone: 817-615-9496
  • Fax: 855-576-4158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number26567
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberK9809
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: