Individual
KENNETH I LICKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
935 YORK DR, DESOTO, TX 75115-2043
(817) 784-0818
(972) 709-5920
Mailing address
PO BOX 120549, ARLINGTON, TX 76012-0549
(817) 303-4521
(972) 709-5920
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
F7819
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
114910601
—
TX
05
—
114910602
—
TX
Enumeration date
09/20/2005
Last updated
10/09/2009
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