Provider Demographics
NPI:1710973870
Name:LICATA, SAMUEL DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:DAVID
Last Name:LICATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:380 SUMMIT AVE
Mailing Address - Street 2:MSO PHYSICIAN BILLING
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-266-5959
Mailing Address - Fax:740-266-5957
Practice Address - Street 1:4000 JOHNSON RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2364
Practice Address - Country:US
Practice Address - Phone:740-266-5959
Practice Address - Fax:740-266-5957
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV18107208600000X
OH35064482208600000X
PAMD048163L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0126291000Medicaid
OH0188381Medicaid
WV9913723Medicare ID - Type Unspecified
G09185Medicare UPIN
WV0785011Medicare ID - Type Unspecified
WV0126291000Medicaid
OH9913724Medicare ID - Type Unspecified