Provider Demographics
NPI:1285651018
Name:LACIVITA, MICHAEL D (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:LACIVITA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:6325 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5822
Practice Address - Country:US
Practice Address - Phone:716-630-1295
Practice Address - Fax:716-250-5999
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0060261213E00000X
NY002240213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02676171Medicaid
NY2700532OtherUNITED HEALTHCARE MEDICAR
NY00027227501OtherUNIVERA
V05654Medicare UPIN
NY000528220001OtherBLUE CROSS
NYRA7374Medicare ID - Type Unspecified
NYP00269107Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NY02676171Medicaid