Provider Demographics
NPI:1831287887
Name:LICUDINE, NORMITA MADAMBA (MD)
Entity Type:Individual
Prefix:DR
First Name:NORMITA
Middle Name:MADAMBA
Last Name:LICUDINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7049 N KILPATRICK AVENUE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712
Mailing Address - Country:US
Mailing Address - Phone:847-677-7264
Mailing Address - Fax:773-379-4034
Practice Address - Street 1:4758 WEST WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644
Practice Address - Country:US
Practice Address - Phone:773-379-4348
Practice Address - Fax:773-379-4034
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036051696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051696Medicaid
IL487530Medicare ID - Type Unspecified
IL036051696Medicaid