Provider Demographics
NPI:1275642183
Name:LICKSTEIN, DAVID ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALAN
Last Name:LICKSTEIN
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 1:5540 PGA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3987
Mailing Address - Country:US
Mailing Address - Phone:561-571-4000
Mailing Address - Fax:561-508-8890
Practice Address - Street 1:5540 PGA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3987
Practice Address - Country:US
Practice Address - Phone:561-571-4000
Practice Address - Fax:561-508-8890
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84765208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17239OtherBLUECROSS BLUESHIELD
FL17239OtherBLUECROSS BLUESHIELD
FLH36320Medicare UPIN
FL17239OtherBLUECROSS BLUESHIELD