Provider Demographics
NPI:1225350200
Name:AMNON LICHT MD INC
Entity Type:Organization
Organization Name:AMNON LICHT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMNON
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-839-3200
Mailing Address - Street 1:9808 VENICE BLVD
Mailing Address - Street 2:SUITE 706
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2732
Mailing Address - Country:US
Mailing Address - Phone:310-839-3200
Mailing Address - Fax:310-839-1247
Practice Address - Street 1:9808 VENICE BLVD
Practice Address - Street 2:SUITE 706
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2732
Practice Address - Country:US
Practice Address - Phone:310-839-3200
Practice Address - Fax:310-839-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32682174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A326820OtherMEDI-CAL
CAA32682Medicare UPIN