=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104895499
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH JOHN LICATA JR. M.D. F.A.C.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2006
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 POST RD STE M5
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07436-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-327-0220
-----------------------------------------------------
Fax | 201-327-4871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 POST RD STE M5
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07436-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-327-0220
-----------------------------------------------------
Fax | 201-327-4871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 55973
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------