Provider Demographics
NPI:1306897780
Name:LICUANAN, JESUS LOMIBAO (MD)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:LOMIBAO
Last Name:LICUANAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6131 ORANGETHORPE AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-1315
Mailing Address - Country:US
Mailing Address - Phone:714-521-1700
Mailing Address - Fax:714-521-1003
Practice Address - Street 1:6131 ORANGETHORPE AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-1315
Practice Address - Country:US
Practice Address - Phone:714-521-1700
Practice Address - Fax:714-521-1003
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A423000Medicaid
CAA-42300Medicare ID - Type Unspecified
CAA-29552Medicare UPIN