Provider Demographics
NPI:1104856012
Name:LICHWA, EDWIN ALPHONSE II (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:ALPHONSE
Last Name:LICHWA
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:612 SNAPDRAGON ST
Mailing Address - Street 2:
Mailing Address - City:WINTERS
Mailing Address - State:CA
Mailing Address - Zip Code:95694-1680
Mailing Address - Country:US
Mailing Address - Phone:530-795-0958
Mailing Address - Fax:
Practice Address - Street 1:500 JEFFERSON BLVD STE B180
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-2394
Practice Address - Country:US
Practice Address - Phone:916-375-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA6985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G65115Medicare UPIN