Provider Demographics
NPI:1740361518
Name:LICATA, PAUL JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JOHN
Last Name:LICATA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:16702 VALLEY VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-5824
Mailing Address - Country:US
Mailing Address - Phone:714-367-5360
Mailing Address - Fax:714-635-5428
Practice Address - Street 1:1717 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-4345
Practice Address - Country:US
Practice Address - Phone:714-635-2642
Practice Address - Fax:714-635-8547
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2022-07-21
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Provider Licenses
StateLicense IDTaxonomies
CAA25662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24524Medicare UPIN