Provider Demographics
NPI:1043205545
Name:LIVECCHI, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LIVECCHI
Suffix:
Gender:M
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 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-9092
Mailing Address - Fax:904-244-9493
Practice Address - Street 1:15255 MAX LEGGETT PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7273
Practice Address - Country:US
Practice Address - Phone:904-456-8297
Practice Address - Fax:904-244-9493
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL130640208100000X, 2081P0004X, 2081P0301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01892222Medicaid
NYP00884039OtherMEDICARE RAILROAD
NY01892222Medicaid
NYRB0022 (GROUP 70008AMedicare PIN