Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 057703 | FL |
N | 207Q00000X | Family Doctor | 057703 | FL |
NPI | 1508874439 |
---|---|
Provider Name | Steven Licata |
First Address | Ft Lauderdale, FL 33308-5530 |
Second Address | Ft Lauderdale, FL 33308-5530 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/08/2006 |
Last Update Date | 26/03/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G77602 | (02) |