Provider Demographics
NPI:1386608248
Name:LICCIARDI, SALVATORE
Entity type:Individual
Prefix:DR
First Name:SALVATORE
Middle Name:
Last Name:LICCIARDI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:COXSACKIE
Mailing Address - State:NY
Mailing Address - Zip Code:12051-1305
Mailing Address - Country:US
Mailing Address - Phone:518-731-7777
Mailing Address - Fax:
Practice Address - Street 1:24 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12051-1305
Practice Address - Country:US
Practice Address - Phone:518-731-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2007-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG10773Medicare UPIN