Provider Demographics
NPI:1467590463
Name:FLORIDA INFECTIOUS DISEASE GROUP PA
Entity Type:Organization
Organization Name:FLORIDA INFECTIOUS DISEASE GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARMELO
Authorized Official - Middle Name:M
Authorized Official - Last Name:LICITRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-423-1039
Mailing Address - Street 1:PO BOX 568766
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32856-8766
Mailing Address - Country:US
Mailing Address - Phone:407-423-1039
Mailing Address - Fax:407-425-2347
Practice Address - Street 1:1012 LUCERNE TER
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1015
Practice Address - Country:US
Practice Address - Phone:407-423-1039
Practice Address - Fax:407-425-2347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40344Medicare PIN