Provider Demographics
NPI:1619661287
Name:LICAJ, JOEY REYNOLD (MD)
Entity type:Individual
Prefix:DR
First Name:JOEY
Middle Name:REYNOLD
Last Name:LICAJ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7603 DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4153
Mailing Address - Country:US
Mailing Address - Phone:843-251-6387
Mailing Address - Fax:
Practice Address - Street 1:1211 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0004
Practice Address - Country:US
Practice Address - Phone:615-322-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program