Provider Demographics
NPI:1205889045
Name:LICCIARDONE, SALVATORE (DO)
Entity type:Individual
Prefix:DR
First Name:SALVATORE
Middle Name:
Last Name:LICCIARDONE
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 1:1319 WICKFORD LN
Mailing Address - Street 2:
Mailing Address - City:LANOKA HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08734-2912
Mailing Address - Country:US
Mailing Address - Phone:609-242-0073
Mailing Address - Fax:
Practice Address - Street 1:74 PASCACK RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1935
Practice Address - Country:US
Practice Address - Phone:201-391-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02322300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
442688Medicare ID - Type Unspecified
NJE06194Medicare UPIN