Provider Demographics
NPI:1447229869
Name:LICZNERSKI, ADAM BOGDAN (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:BOGDAN
Last Name:LICZNERSKI
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 1:826 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:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189322-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01680515Medicaid
NYAA0167OtherGROUP NUMBER
BB3693Medicare ID - Type Unspecified
NYAA0167OtherGROUP NUMBER