Provider Demographics
NPI:1740738632
Name:DAVID A LICKSTEIN MD LLC
Entity Type:Organization
Organization Name:DAVID A LICKSTEIN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LICKSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-571-4000
Mailing Address - Street 1:5540 PGA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3987
Mailing Address - Country:US
Mailing Address - Phone:561-571-4000
Mailing Address - Fax:561-508-8890
Practice Address - Street 1:5540 PGA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3987
Practice Address - Country:US
Practice Address - Phone:561-847-0970
Practice Address - Fax:561-508-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84765208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIX755AMedicare PIN