Individual
DR. JIM PAUL LICANDRO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
405 WOODLAWN RD, LONG GROVE, IA 52756
(832) 425-7457
(563) 285-5446
Mailing address
5261 BOULDER DR APT D, WEST DES MOINES, IA 50265-7823
(563) 340-4387
(563) 424-7234
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
00705
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1197210
—
IA
Enumeration date
07/07/2005
Last updated
07/22/2018
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