Provider Demographics
NPI:1033295142
Name:EDWARD E ICAZA MD PA
Entity type:Organization
Organization Name:EDWARD E ICAZA MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:ICAZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-615-9496
Mailing Address - Street 1:5801 OAKBEND TRL STE 270
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3922
Mailing Address - Country:US
Mailing Address - Phone:817-615-9496
Mailing Address - Fax:
Practice Address - Street 1:5801 OAKBEND TRL STE 270
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3922
Practice Address - Country:US
Practice Address - Phone:817-615-9496
Practice Address - Fax:855-576-4158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084N0400X
TXK98092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0072JAOtherBCBS
TXK9809OtherNEUROLOGIST
TX0072JAOtherBCBS
TXTXB138278Medicare PIN