Provider Demographics
NPI:1417995325
Name:LICHTI, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:LICHTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:380 E 1500 S
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3940
Mailing Address - Country:US
Mailing Address - Phone:435-657-2711
Mailing Address - Fax:435-657-2716
Practice Address - Street 1:380 E 1500 S
Practice Address - Street 2:SUITE 202
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3940
Practice Address - Country:US
Practice Address - Phone:435-657-2711
Practice Address - Fax:435-657-2716
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT1835651205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870516264009Medicaid
UT870516264009Medicaid
UTB67964Medicare UPIN