Provider Demographics
NPI:1083690051
Name:LICATINO, MARK ANTHONY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:LICATINO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5717 BALCONES DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4203
Mailing Address - Country:US
Mailing Address - Phone:512-327-7000
Mailing Address - Fax:512-314-1660
Practice Address - Street 1:85 LOOP 150 W
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3930
Practice Address - Country:US
Practice Address - Phone:512-303-7300
Practice Address - Fax:512-303-2148
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2442TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX911390OtherBLOCK VISION
VP11653OtherGE WELLNESS
TX117899802Medicaid
TX10013121OtherAMERIGROUP
TX117899803Medicaid
146573100OtherFIRST CARE
NY32787-013OtherDAVIS VISION
TX8114413OtherBLUELINK
TX4511497OtherAETNA
TX88Y393OtherBLUE CROSS BLUE SHIELD
OHTX2442OtherEYEMED
TX4511497OtherAETNA
TX911390OtherBLOCK VISION
TX117899803Medicaid
TX88Y393Medicare PIN
NY32787-013OtherDAVIS VISION