Individual
CARLOS E LICON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3750 COMMERCIAL AVE, SAN ANTONIO, TX 78221-3117
(210) 334-3760
(210) 923-6355
Mailing address
3750 COMMERCIAL AVE, SAN ANTONIO, TX 78221-3117
(210) 334-3700
(210) 922-0162
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M4290
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
184983801
—
TX
01
—
8G8247
BCBS
TX
01
—
94846
CARELINK
TX
01
—
X0148767
DPS
TX
Enumeration date
10/27/2006
Last updated
03/07/2023
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