Provider Demographics
NPI:1336141647
Name:LICHTENSTEIN, JOHN STUART (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STUART
Last Name:LICHTENSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:ROUTE 209 BOX 346
Mailing Address - Street 2:
Mailing Address - City:WAWARSING
Mailing Address - State:NY
Mailing Address - Zip Code:12489-0346
Mailing Address - Country:US
Mailing Address - Phone:845-626-5500
Mailing Address - Fax:845-626-5707
Practice Address - Street 1:ROUTE 209 BOX 346
Practice Address - Street 2:
Practice Address - City:WAWARSING
Practice Address - State:NY
Practice Address - Zip Code:12489-0346
Practice Address - Country:US
Practice Address - Phone:845-626-5500
Practice Address - Fax:845-626-5707
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00189491Medicaid
NY361341Medicare ID - Type UnspecifiedMEDICARE
NYA63562Medicare UPIN