Provider Demographics
NPI:1174536759
Name:LICKSTEIN, LARRY HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:HOWARD
Last Name:LICKSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8322 BELLONA AVENUE SUITE 300
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2012
Mailing Address - Country:US
Mailing Address - Phone:410-296-0414
Mailing Address - Fax:410-296-0412
Practice Address - Street 1:MICHAEL D COHEN MD PA
Practice Address - Street 2:8322 BELLONA AVENUE SUITE 300
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2012
Practice Address - Country:US
Practice Address - Phone:410-296-0414
Practice Address - Fax:410-296-0412
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064062208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H20834Medicare UPIN
735MN825Medicare ID - Type Unspecified