Provider Demographics
NPI:1740711076
Name:LICATA, JOHN PASCHAL (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PASCHAL
Last Name:LICATA
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 2895
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35056-2895
Mailing Address - Country:US
Mailing Address - Phone:256-735-5075
Mailing Address - Fax:256-964-3382
Practice Address - Street 1:1800 AL HIGHWAY 157
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35058-1271
Practice Address - Country:US
Practice Address - Phone:256-735-5075
Practice Address - Fax:256-964-3382
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-00623208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALMD47191OtherMEDICAL LICENSE