Provider Demographics
NPI:1306841473
Name:LICHT, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:LICHT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:805 CENTURY MEDICAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2100
Mailing Address - Country:US
Mailing Address - Phone:321-268-6868
Mailing Address - Fax:321-267-2713
Practice Address - Street 1:825 CENTURY MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2113
Practice Address - Country:US
Practice Address - Phone:321-268-6868
Practice Address - Fax:321-267-2713
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME68004174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101986000Medicaid