Provider Demographics
NPI:1780753251
Name:SICANGCO, HOMERO (MD)
Entity type:Individual
Prefix:MR
First Name:HOMERO
Middle Name:
Last Name:SICANGCO
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 1:2950 MONTILLA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-5526
Mailing Address - Country:US
Mailing Address - Phone:904-461-8906
Mailing Address - Fax:904-461-8907
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:#105-B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-461-8906
Practice Address - Fax:904-461-8907
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002981500Medicaid
FL2762240OtherCIGNA
FL51003OtherBCBS