1083690051 NPI number — DR. MARK ANTHONY LICATINO O.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083690051 NPI number — DR. MARK ANTHONY LICATINO O.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

LICATINO

Provider First Name:

MARK

Provider Middle Name:

ANTHONY

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

O.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1083690051

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

02/01/2010

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

5717 BALCONES DR

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

AUSTIN

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

78731-4203

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

512-327-7000

Provider Business Mailing Address Fax Number:

512-314-1660

Provider First Line Business Practice Location Address:

85 LOOP 150 W

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

BASTROP

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

78602-3930

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

512-303-7300

Provider Business Practice Location Address Fax Number:

512-303-2148

Provider Enumeration Date:

12/21/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 152W00000X , with the licence number:  2442TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 911390 . This is a "BLOCK VISION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: VP11653 . This is a "GE WELLNESS" identifier . This identifiers is of the category "OTHER".
• Identifier: 117899802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 10013121 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 117899803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 146573100 . This is a "FIRST CARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 32787-013 . This is a "DAVIS VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 8114413 . This is a "BLUELINK" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 4511497 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 88Y393 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: TX2442 . This is a "EYEMED" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".