Provider Demographics
NPI:1295029072
Name:LICATA, JAMES (LDO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:LICATA
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2048 E BASELINE RD # C-6
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6969
Mailing Address - Country:US
Mailing Address - Phone:480-632-5075
Mailing Address - Fax:480-507-0836
Practice Address - Street 1:2048 E BASELINE RD # C-6
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6969
Practice Address - Country:US
Practice Address - Phone:480-632-5075
Practice Address - Fax:480-507-0836
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ748156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician