Basic Information
| Provider Information | |||||||||
| NPI: | 1306814579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICATA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3040 AMSDELL RD | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140755835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166499000 | ||||||||
| FaxNumber: | 7166499005 | ||||||||
| Practice Location | |||||||||
| Address1: | 2157 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142142648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166499000 | ||||||||
| FaxNumber: | 7166499005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 184241-1 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | 184241 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00026372703 | 01 | NY | UNIVERA HEALTHCARE | OTHER | 300080525 | 01 | NY | RR MEDICARE | OTHER | 040426000284 | 01 | NY | FIDELIS CARE OF NEW YORK | OTHER | 113586FF | 01 | NY | PREFERRED CARE | OTHER | 1609206 | 01 | NY | INDEPENDENT HEALTH | OTHER | 01528734 | 05 | NY | MEDICAID | 000523460013 | 01 | NY | BCBS | OTHER |