Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 5901001880 | MI |
NPI | 1568469500 |
---|---|
Provider Name | Dr. Liljana Licovski |
First Address | Brownstown, MI 48183 |
Second Address | Brownstown Twp, MI 48183-1021 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2005 |
Last Update Date | 16/12/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3515935 | (05) | MI |
U79899 | (02) | MI |