Provider Demographics
NPI:1356321988
Name:LICHT, JONATHAN M (MD)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:M
Last Name:LICHT
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 1:4033 3RD AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2117
Mailing Address - Country:US
Mailing Address - Phone:619-294-9292
Mailing Address - Fax:
Practice Address - Street 1:4033 3RD AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2117
Practice Address - Country:US
Practice Address - Phone:619-294-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG438922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G438921Medicaid
CA00G438921Medicaid
CAB46476Medicare UPIN