Provider Demographics
NPI:1356710438
Name:PAUL JOHN LICATA MD
Entity type:Organization
Organization Name:PAUL JOHN LICATA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LICATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-448-9728
Mailing Address - Street 1:25431 CABOT RD
Mailing Address - Street 2:STE 115
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5518
Mailing Address - Country:US
Mailing Address - Phone:949-448-9728
Mailing Address - Fax:949-448-9732
Practice Address - Street 1:25431 CABOT RD
Practice Address - Street 2:STE 115
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5518
Practice Address - Country:US
Practice Address - Phone:949-448-9728
Practice Address - Fax:949-448-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25662CA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care