Healthcare Provider Details

I. General information

NPI: 1306814579
Provider Name (Legal Business Name): MICHAEL LICATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2157 MAIN ST
BUFFALO NY
14214-2648
US

IV. Provider business mailing address

3040 AMSDELL RD
HAMBURG NY
14075-5835
US

V. Phone/Fax

Practice location:
  • Phone: 716-649-9000
  • Fax: 716-649-9005
Mailing address:
  • Phone: 716-649-9000
  • Fax: 716-649-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number184241-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number184241
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: