Healthcare Provider Details

I. General information

NPI: 1659347342
Provider Name (Legal Business Name): CARMELO M LICITRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 W STATE ROAD 434 STE 305
LONGWOOD FL
32750-5166
US

IV. Provider business mailing address

521 W STATE ROAD 434 STE 305
LONGWOOD FL
32750-5166
US

V. Phone/Fax

Practice location:
  • Phone: 407-423-1039
  • Fax: 407-425-2347
Mailing address:
  • Phone: 407-423-1039
  • Fax: 407-425-2347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME0042655
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: