Provider Demographics
NPI:1336225747
Name:LICATA, PETER JOSEPH (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
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 1:5410 W SAHARA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3307
Mailing Address - Country:US
Mailing Address - Phone:702-362-2500
Mailing Address - Fax:702-876-6581
Practice Address - Street 1:5410 W SAHARA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3307
Practice Address - Country:US
Practice Address - Phone:702-362-2500
Practice Address - Fax:702-876-6581
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2002566Medicaid
NV2002566Medicaid
NV08WCHCK01Medicare ID - Type Unspecified