Provider Demographics
NPI:1407825151
Name:LICZNERSKI, BARBARA TERESA (MD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:TERESA
Last Name:LICZNERSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 WASHINGTON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4065
Mailing Address - Country:US
Mailing Address - Phone:315-786-1500
Mailing Address - Fax:315-786-2074
Practice Address - Street 1:826 WASHINGTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4065
Practice Address - Country:US
Practice Address - Phone:315-786-1500
Practice Address - Fax:315-786-2074
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187504-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01563780Medicaid
NY070012711OtherRAILROAD MEDICARE
NYAA0167OtherGROUP NUMBER
NY01563780Medicaid
F70199Medicare UPIN