MEDICARE: DOLLEEN LICCIARDI MD

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	208000000X	Pediatrics Physician	17300	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629072558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOLLEEN LICCIARDI MD

Provider Business Mailing Address
First Line	:	298 HENRY CLAY AVE
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70118-5720
Country	:	US
Telephone Number	:	504-896-9827
Fax Number	:	504-894-5370

Provider Business Practice Location Address
First Line	:	141 ORMOND CENTER CT
Second Line	:
City	:	DESTREHAN
State	:	LA
Zip	:	70047-2548
Country	:	US
Telephone Number	:	985-764-7337
Fax Number	:	985-764-5333

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	01/07/2011

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Directions to “ DOLLEEN LICCIARDI MD” Practice Location

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