Individual
DR. RAYMOND PAUL LICCINI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
16261 BASS RD STE 300, FORT MYERS, FL 33908
(239) 343-6410
(239) 343-4014
Mailing address
PO BOX 2147, FORT MYERS, FL 33902-2147
(239) 343-6410
(239) 343-4014
Taxonomy
Speciality
Code
Description
License number
State
207RI0011X
Interventional Cardiology Physician
Primary
ME68201
FL
207UN0901X
Nuclear Cardiology Physician
ME68201
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
060070568
MEDICARE RR
FL
01
—
27065
BCBS
FL
05
—
377898300
—
FL
01
—
820580815
TAX ID
FL
Enumeration date
08/22/2005
Last updated
03/29/2021
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