Provider Demographics
NPI:1861562779
Name:LICCINI, MARK STEPHEN (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
Last Name:LICCINI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:31 WIMBLEDON WAY
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2087
Mailing Address - Country:US
Mailing Address - Phone:215-205-4231
Mailing Address - Fax:
Practice Address - Street 1:93 COOPER RD STE 100
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4910
Practice Address - Country:US
Practice Address - Phone:856-770-1920
Practice Address - Fax:856-770-1925
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB 07743500207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology