MEDICARE: JULIO LICINIO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	C50445	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00C504450	OTHER	CA	MEDICAL
2	ME97202	OTHER	FL	MEDICAL

General Provider Information

NPI Number	:	1770516213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIO LICINIO MD

Provider Business Mailing Address
First Line	:	3109 GRAND AVE
Second Line	:	# 205
City	:	MIAMI
State	:	FL
Zip	:	33133-5103
Country	:	US
Telephone Number	:	305-570-7301
Fax Number	:

Provider Business Practice Location Address
First Line	:	3109 GRAND AVE
Second Line	:	SUITE 205
City	:	MIAMI
State	:	FL
Zip	:	33133-5103
Country	:	US
Telephone Number	:	305-570-7301
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	04/30/2014

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Directions to “ JULIO LICINIO MD” Practice Location

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