MEDICARE: DR. IRINA LICEA 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	207Q00000X	Family Medicine Physician	ME 100912	FL

General Provider Information

NPI Number	:	1649454091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRINA LICEA MD

Provider Business Mailing Address
First Line	:	1321 NW 14TH ST STE 102
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33125-1653
Country	:	US
Telephone Number	:	305-545-4980
Fax Number	:	305-545-4913

Provider Business Practice Location Address
First Line	:	1321 NW 14TH ST STE 102
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33125-1653
Country	:	US
Telephone Number	:	305-545-4980
Fax Number	:	305-545-4913

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

Provider Enumeration Date	:	12/20/2007
Last Update Date	:	06/09/2014

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