Provider Demographics
NPI:1093711152
Name:ILIVICKY, HOWARD JAY (MD)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:JAY
Last Name:ILIVICKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4132 KEATON CROSSING BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8222
Mailing Address - Country:US
Mailing Address - Phone:636-244-3589
Mailing Address - Fax:636-244-3594
Practice Address - Street 1:330 1ST CAPITOL DR
Practice Address - Street 2:STE 390
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2852
Practice Address - Country:US
Practice Address - Phone:636-949-5760
Practice Address - Fax:636-949-0729
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1187862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
415921OtherHEALTHLINK
122112OtherBLUE CROSS BLUE SHIELD
122112OtherBLUE CROSS BLUE SHIELD
007011899Medicare ID - Type Unspecified