Basic Information
Provider Information
NPI: 1790772002
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LICATA
FirstName: PAUL
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 629D LOWTHER RD
Address2:  
City: LEWISBERRY
State: PA
PostalCode: 173399527
CountryCode: US
TelephoneNumber: 7179325200
FaxNumber: 7179323095
Practice Location
Address1: 629D LOWTHER RD
Address2:  
City: LEWISBERRY
State: PA
PostalCode: 173399527
CountryCode: US
TelephoneNumber: 7179325200
FaxNumber: 7179323095
Other Information
ProviderEnumerationDate: 10/03/2005
LastUpdateDate: 01/18/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085R0202XMD073064LPAN Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
2085R0204XMD073064LPAY Allopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology

ID Information
IDTypeStateIssuerDescription
10109789305PA MEDICAID


Home