Provider Demographics
NPI:1669468666
Name:LIVICA, EDGARDO MESIAS (RPT)
Entity type:Individual
Prefix:MR
First Name:EDGARDO
Middle Name:MESIAS
Last Name:LIVICA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1577 LURTING AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1509
Mailing Address - Country:US
Mailing Address - Phone:718-822-8490
Mailing Address - Fax:
Practice Address - Street 1:787 LYDIG AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2144
Practice Address - Country:US
Practice Address - Phone:718-775-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-25
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015653261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02716585Medicaid
NY0129225OtherGHI
NY2558827OtherUNITED HEALTHCARE
NY0129225OtherGHI