Provider Demographics
NPI:1760478010
Name:LICOPANTIS, DEAN PETER (DPM)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:PETER
Last Name:LICOPANTIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 POCONO RD
Mailing Address - Street 2:#209
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2901
Mailing Address - Country:US
Mailing Address - Phone:973-331-7900
Mailing Address - Fax:973-331-7999
Practice Address - Street 1:16 POCONO RD
Practice Address - Street 2:#209
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2901
Practice Address - Country:US
Practice Address - Phone:973-331-7900
Practice Address - Fax:973-331-7999
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD001877213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0943908Medicaid
NJ24223299834OtherBLUE CROSS
NJ24223299834OtherBLUE CROSS
NJ578412Medicare PIN