Provider Demographics
NPI:1629072558
Name:LICCIARDI, DOLLEEN (MD)
Entity Type:Individual
Prefix:
First Name:DOLLEEN
Middle Name:
Last Name:LICCIARDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 HENRY CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5720
Mailing Address - Country:US
Mailing Address - Phone:504-896-9827
Mailing Address - Fax:504-894-5370
Practice Address - Street 1:141 ORMOND CENTER CT
Practice Address - Street 2:
Practice Address - City:DESTREHAN
Practice Address - State:LA
Practice Address - Zip Code:70047-2548
Practice Address - Country:US
Practice Address - Phone:985-764-7337
Practice Address - Fax:985-764-5333
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1364045Medicaid