Healthcare Provider Details

I. General information

NPI: 1457411993
Provider Name (Legal Business Name): ROBERT JOSEPH CRAIG LACIVITA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

450 W 42ND ST APT. 14Q
NEW YORK NY
10036-6800
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-7703
  • Fax:
Mailing address:
  • Phone: 617-834-0628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number274890
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: