Provider Demographics
NPI:1295908598
Name:LICCARDI, TERESA MARIE (MD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:LICCARDI
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:PO BOX 1168
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34106-1168
Mailing Address - Country:US
Mailing Address - Phone:908-461-8050
Mailing Address - Fax:
Practice Address - Street 1:780 5TH AVE S STE 200
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-6632
Practice Address - Country:US
Practice Address - Phone:239-366-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303252207RN0300X
NJ25MA05756600207RN0300X
FLME127037207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6252109Medicaid
NJ721251DPSMedicare UPIN