Provider Demographics
NPI:1306814579
Name:LICATA, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LICATA
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 1:3040 AMSDELL RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5835
Mailing Address - Country:US
Mailing Address - Phone:716-649-9000
Mailing Address - Fax:716-649-9005
Practice Address - Street 1:2157 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2648
Practice Address - Country:US
Practice Address - Phone:716-649-9000
Practice Address - Fax:716-649-9005
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184241-12085B0100X
NY1842412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026372703OtherUNIVERA HEALTHCARE
NY300080525OtherRR MEDICARE
NY040426000284OtherFIDELIS CARE OF NEW YORK
NY113586FFOtherPREFERRED CARE
NY1609206OtherINDEPENDENT HEALTH
NY01528734Medicaid
NY000523460013OtherBCBS
NY14464IMedicare PIN
NYF92231Medicare UPIN
NY300080525OtherRR MEDICARE
NYRA1913Medicare PIN
NY14422CMedicare PIN