Provider Demographics
NPI:1811193253
Name:LICATA, THOMAS C (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:C
Last Name:LICATA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 E LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1327
Mailing Address - Country:US
Mailing Address - Phone:856-566-7121
Mailing Address - Fax:
Practice Address - Street 1:18 E LAUREL RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1327
Practice Address - Country:US
Practice Address - Phone:856-566-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08708700207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ184658ZEDBMedicare PIN
NJ184658UKEMedicare PIN