Provider Demographics
NPI:1568469500
Name:LICOVSKI, LILJANA (DPM)
Entity Type:Individual
Prefix:DR
First Name:LILJANA
Middle Name:
Last Name:LICOVSKI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19723 ALLEN ROAD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48183
Mailing Address - Country:US
Mailing Address - Phone:734-479-8383
Mailing Address - Fax:734-479-8382
Practice Address - Street 1:19723 ALLEN RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1021
Practice Address - Country:US
Practice Address - Phone:734-479-8383
Practice Address - Fax:734-479-8382
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001880213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3515935Medicaid
MIU79899Medicare UPIN
MI3515935Medicaid
MI1254620001Medicare NSC