Individual
DR. GUSTAVO LICEA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3513 W ALBERTA RD, EDINBURG, TX 78539-8466
(956) 664-9771
(956) 664-9773
Mailing address
PO BOX 720550, MCALLEN, TX 78504-0550
(956) 664-9771
(956) 664-9773
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
J2657
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
130477604
—
TX
Enumeration date
07/11/2006
Last updated
07/08/2007
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