Provider Demographics
NPI:1114976289
Name:LICHTOR, TERENCE R (MD)
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:R
Last Name:LICHTOR
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 1:2800 WESTHILL DR
Mailing Address - Street 2:STE 200
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3771
Mailing Address - Country:US
Mailing Address - Phone:715-843-1000
Mailing Address - Fax:715-843-1001
Practice Address - Street 1:2800 WESTHILL DR
Practice Address - Street 2:STE 200
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-3771
Practice Address - Country:US
Practice Address - Phone:715-843-1000
Practice Address - Fax:715-843-1001
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-065063207T00000X
MT103790207T00000X
SD8147207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D16519Medicare UPIN
IL294430Medicare ID - Type Unspecified
ILD16519Medicare UPIN