Provider Demographics
NPI:1427294370
Name:ICOCHEA, ROSENDO SEGUNDO
Entity type:Individual
Prefix:
First Name:ROSENDO
Middle Name:SEGUNDO
Last Name:ICOCHEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40-23 A JUNCTION BLVD
Mailing Address - Street 2:2 FLOOR
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-672-2522
Mailing Address - Fax:
Practice Address - Street 1:40-23 A JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-672-2522
Practice Address - Fax:718-779-0782
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-24
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193456208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery