Provider Demographics
NPI:1841341005
Name:LICCIARDI, LUDWIG (MD)
Entity type:Individual
Prefix:
First Name:LUDWIG
Middle Name:
Last Name:LICCIARDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9020 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-5908
Mailing Address - Country:US
Mailing Address - Phone:718-836-8888
Mailing Address - Fax:718-680-1838
Practice Address - Street 1:9020 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-5908
Practice Address - Country:US
Practice Address - Phone:718-836-8888
Practice Address - Fax:718-680-1838
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129124207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB13101Medicare UPIN
NY33A182Medicare ID - Type Unspecified