Basic Information
| Provider Information | |||||||||
| NPI: | 1780753251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SICANGCO | ||||||||
| FirstName: | HOMERO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2950 MONTILLA DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322465526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044618906 | ||||||||
| FaxNumber: | 9044618907 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 PLANTATION ISLAND DR S | ||||||||
| Address2: | #105-B | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320803108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044618906 | ||||||||
| FaxNumber: | 9044618907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 07/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME71363 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 002981500 | 05 | FL | MEDICAID | 2762240 | 01 | FL | CIGNA | OTHER | 51003 | 01 | FL | BCBS | OTHER |