Provider Demographics
NPI:1508874439
Name:LICATA, STEVEN (DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:LICATA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-5530
Mailing Address - Country:US
Mailing Address - Phone:954-563-2707
Mailing Address - Fax:954-563-7009
Practice Address - Street 1:4109 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-5530
Practice Address - Country:US
Practice Address - Phone:954-563-2707
Practice Address - Fax:954-563-7009
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL057703204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G77602Medicare UPIN
E1114ZMedicare ID - Type Unspecified