Provider Demographics
NPI:1740262740
Name:LACIVITA, LEONARD P (MD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:P
Last Name:LACIVITA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:39525 W 14 MILE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1632
Mailing Address - Country:US
Mailing Address - Phone:248-926-6673
Mailing Address - Fax:248-926-6683
Practice Address - Street 1:39525 W 14 MILE RD
Practice Address - Street 2:STE 101
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1632
Practice Address - Country:US
Practice Address - Phone:248-926-6673
Practice Address - Fax:248-926-6683
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301406820207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3279382Medicaid
MI3279382Medicaid
E38050Medicare UPIN