Provider Demographics
NPI:1669522769
Name:LICATA, ROBERT M (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:LICATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6200 COTTAGE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-2983
Mailing Address - Country:US
Mailing Address - Phone:571-216-1272
Mailing Address - Fax:
Practice Address - Street 1:120 COASTAL HORIZONS DR
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-6094
Practice Address - Country:US
Practice Address - Phone:910-754-4515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010270662084P0800X
NC2014-015102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D18115Medicare UPIN
LI108206Medicare ID - Type Unspecified