Individual
IVAN ALEXIS LICEA TAMAYO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4371 NARROW LANE RD, MONTGOMERY, AL 36116-2971
(334) 613-3680
Mailing address
4371 NARROW LANE RD, MONTGOMERY, AL 36116-2971
(334) 613-3680
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
L3510R
AL
207Q00000X
Family Medicine Physician
ME 118521
FL
Other
Enumeration date
01/31/2014
Last updated
01/31/2014
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