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General NPI Number Information
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NPI Number | 1740682673
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Entity Type | Individual
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Provider Name | BENNY ILLICKAL
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Gender | Male
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Dates
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Enumeration Date | 09/23/2014
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Last Update Date | 09/23/2014
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Provider Practice Location Address
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Address Line | 291 STONE MOUNTAIN DR
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City | SUNNYVALE
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State | TX
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Zip | 75182-2655
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Country | US
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Telephone | 972-352-7260
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Fax |
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Provider Business Mailing Address
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Address Line | 291 STONE MOUNTAIN DR
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City | SUNNYVALE
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State | TX
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Zip | 75182-2655
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Country | US
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Telephone | 972-352-7260
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Fax |
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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 | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | R37333
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License Number State | TX
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