Provider Demographics
NPI:1023409984
Name:LIVETTE, LUCIOL D (MD)
Entity type:Individual
Prefix:MRS
First Name:LUCIOL
Middle Name:D
Last Name:LIVETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1877 FORTUNE RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4428
Mailing Address - Country:US
Mailing Address - Phone:407-943-8600
Mailing Address - Fax:
Practice Address - Street 1:109 N DOVERPLUM AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-3309
Practice Address - Country:US
Practice Address - Phone:407-943-8600
Practice Address - Fax:833-464-3641
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19121208D00000X
FLACN1565208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121624600Medicaid