MEDICARE: DR. DAVID ALAN LICKSTEIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	ME84765	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17239	OTHER	FL	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1275642183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID ALAN LICKSTEIN M.D.

Provider Business Mailing Address
First Line	:	5540 PGA BLVD
Second Line	:	SUITE 200
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-3987
Country	:	US
Telephone Number	:	561-571-4000
Fax Number	:	561-508-8890

Provider Business Practice Location Address
First Line	:	5540 PGA BLVD
Second Line	:	SUITE 200
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-3987
Country	:	US
Telephone Number	:	561-571-4000
Fax Number	:	561-508-8890

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	05/04/2017

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