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General NPI Number Information
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NPI Number | 1134121940
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Entity Type | Individual
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Provider Name | EDWARD EARL ICAZA MD
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Gender | Male
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 5801 OAKBEND TRL STE 270
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City | FORT WORTH
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State | TX
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Zip | 76132-3922
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Country | US
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Telephone | 817-615-9496
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Fax | 855-576-4158
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Provider Business Mailing Address
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Address Line | 5801 OAKBEND TRL STE 270
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City | FORT WORTH
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State | TX
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Zip | 76132-3922
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Country | US
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Telephone | 817-615-9496
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Fax | 855-576-4158
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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 | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 26567
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | K9809
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License Number State | TX
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