Provider Demographics
NPI:1821096249
Name:MILICIA, MARLYN V (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARLYN
Middle Name:V
Last Name:MILICIA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:MARLYN
Other - Middle Name:V
Other - Last Name:CLAUDIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 SAVANNA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766
Mailing Address - Country:US
Mailing Address - Phone:631-244-2930
Mailing Address - Fax:631-244-2930
Practice Address - Street 1:7905 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11766
Practice Address - Country:US
Practice Address - Phone:631-244-2930
Practice Address - Fax:631-651-2794
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-09
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6016-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPJ2795Medicare UPIN