MEDICARE: KENNETH I LICKER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	F7819	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891781316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH I LICKER MD

Provider Business Mailing Address
First Line	:	PO BOX 120549
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-0549
Country	:	US
Telephone Number	:	817-303-4521
Fax Number	:	972-709-5920

Provider Business Practice Location Address
First Line	:	935 YORK DR
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-2043
Country	:	US
Telephone Number	:	817-784-0818
Fax Number	:	972-709-5920

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	10/09/2009

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Directions to “ KENNETH I LICKER MD” Practice Location

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