Provider Demographics
NPI:1558508192
Name:LICETTI, STEPHEN CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CHARLES
Last Name:LICETTI
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 1:210 YORKTOWN PLZ
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 SCOTCH RD STE 1
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-2528
Practice Address - Country:US
Practice Address - Phone:609-498-7670
Practice Address - Fax:609-385-4150
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08833000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine