1538172523 NPI number — DR. CHARLES J LICATA DO

Table of content: DR. CHARLES J LICATA DO (NPI 1538172523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538172523 NPI number — DR. CHARLES J LICATA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LICATA
Provider First Name:
CHARLES
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1538172523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 FARM SPRINGS RD
Provider Second Line Business Mailing Address:
PROHEALTH PHYSICIANS
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06032-2573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-284-5200
Provider Business Mailing Address Fax Number:
860-284-5333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 CLARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06010-4068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-583-7700
Provider Business Practice Location Address Fax Number:
860-589-7656
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  000359 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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