Provider Demographics
NPI:1114126158
Name:LICHTBLAU, ETHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:LICHTBLAU
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 1:1531 THE ESPLANADE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3310
Mailing Address - Country:US
Mailing Address - Phone:530-332-7300
Mailing Address - Fax:
Practice Address - Street 1:1531 THE ESPLANADE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3310
Practice Address - Country:US
Practice Address - Phone:530-332-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88013207X00000X
ND10692207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG88013OtherCA LICENSE
ND14386Medicaid
ND14386Medicaid