Provider Demographics
NPI:1033197694
Name:LICATA, ANTONIO M (DO)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:M
Last Name:LICATA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 632317
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2317
Mailing Address - Country:US
Mailing Address - Phone:937-208-4380
Mailing Address - Fax:937-208-3843
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:3 FL / ANES. DEPT
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-208-4380
Practice Address - Fax:937-208-3843
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005132207L00000X
OH34.00512207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0932138Medicaid
OHLI0743193Medicare UPIN
OHF62023Medicare UPIN