Provider Demographics
NPI:1619969078
Name:LICCINI, RAYMOND PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:PAUL
Last Name:LICCINI
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6410
Mailing Address - Fax:239-343-4014
Practice Address - Street 1:16261 BASS RD STE 300
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-343-6410
Practice Address - Fax:239-343-4014
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68201207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060070568OtherMEDICARE RR
FL27065OtherBCBS
FL377898300Medicaid
FL820580815OtherTAX ID
FL820580815OtherTAX ID
FL377898300Medicaid