Provider Demographics
NPI:1548299225
Name:LICEA, ROSAURA (MD)
Entity type:Individual
Prefix:
First Name:ROSAURA
Middle Name:
Last Name:LICEA
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 1:5712 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-4222
Mailing Address - Country:US
Mailing Address - Phone:708-656-5485
Mailing Address - Fax:708-656-5657
Practice Address - Street 1:5712 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-4222
Practice Address - Country:US
Practice Address - Phone:708-656-5485
Practice Address - Fax:708-656-5657
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-091269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091269Medicaid
ILK30405OtherMEDICARE INDIVIDUAL PTAN
IL036091269Medicaid