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General NPI Number Information
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NPI Number | 1114928066
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Entity Type | Individual
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Provider Name | ROMEO GONZAGA ICASIANO MD
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Gender | Male
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Dates
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Enumeration Date | 08/02/2005
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Last Update Date | 04/10/2012
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Provider Practice Location Address
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Address Line | 947 SO 5TH ST
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City | MONTROSE
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State | CO
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Zip | 81401-5716
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Country | US
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Telephone | 870-249-2421
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Fax | 970-249-8897
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Provider Business Mailing Address
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Address Line | 947 SO 5TH ST
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City | MONTROSE
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State | CO
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Zip | 81401-5716
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Country | US
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Telephone | 870-249-2421
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Fax | 970-249-8897
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 37326
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License Number State | CO
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