Provider Demographics
NPI:1538354089
Name:TOFFEL-LICCINI, JUDITH (MD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:TOFFEL-LICCINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CARROTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-7531
Mailing Address - Country:US
Mailing Address - Phone:239-939-3509
Mailing Address - Fax:239-939-3509
Practice Address - Street 1:20 CARROTWOOD CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7531
Practice Address - Country:US
Practice Address - Phone:239-939-3509
Practice Address - Fax:239-939-3509
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105874208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAE67277Medicare UPIN