Healthcare Provider Details

I. General information

NPI: 1790746790
Provider Name (Legal Business Name): SERRIE C LICO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 W SUNSET RD STE 110
LAS VEGAS NV
89113-2244
US

IV. Provider business mailing address

801 S RANCHO DR STE E6
LAS VEGAS NV
89106-3812
US

V. Phone/Fax

Practice location:
  • Phone: 702-240-6482
  • Fax:
Mailing address:
  • Phone: 702-240-6482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number25MA10202300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD068831L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number35.122143
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number24505
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: