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General NPI Number Information
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NPI Number | 1649454091
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Entity Type | Individual
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Provider Name | IRINA LICEA MD
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Gender | Female
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Dates
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Enumeration Date | 12/20/2007
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Last Update Date | 06/09/2014
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Provider Practice Location Address
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Address Line | 1321 NW 14TH ST STE 102
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City | MIAMI
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State | FL
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Zip | 33125-1653
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Country | US
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Telephone | 305-545-4980
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Fax | 305-545-4913
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Provider Business Mailing Address
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Address Line | 1321 NW 14TH ST STE 102
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City | MIAMI
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State | FL
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Zip | 33125-1653
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Country | US
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Telephone | 305-545-4980
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Fax | 305-545-4913
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME 100912
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License Number State | FL
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