Provider Demographics
NPI:1407096720
Name:PAUL J. LICATA MD INC.
Entity Type:Organization
Organization Name:PAUL J. LICATA MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LICATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-827-8890
Mailing Address - Street 1:3356 W BALL RD STE 206
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3728
Mailing Address - Country:US
Mailing Address - Phone:714-827-8890
Mailing Address - Fax:714-827-8905
Practice Address - Street 1:3356 W BALL RD
Practice Address - Street 2:SUITE 206
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3702
Practice Address - Country:US
Practice Address - Phone:714-827-8890
Practice Address - Fax:714-827-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-26
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25662163WG0000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BS00A256626OtherBLUE SHIELD
CA00A25662Medicaid
BS00A256626OtherBLUE SHIELD
CAA24524Medicare UPIN