Provider Demographics
NPI:1669895223
Name:LICEA TAMAYO, IVAN ALEXIS (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:ALEXIS
Last Name:LICEA TAMAYO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 NARROW LANE RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2971
Mailing Address - Country:US
Mailing Address - Phone:334-613-3680
Mailing Address - Fax:
Practice Address - Street 1:4371 NARROW LANE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2971
Practice Address - Country:US
Practice Address - Phone:334-613-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 118521207Q00000X
ALL3510R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine