Provider Demographics
NPI:1487627568
Name:LICHTENBERG, KATHERINE R (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:R
Last Name:LICHTENBERG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:R
Other - Last Name:EASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12255 DE PAUL DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:SUITE 600
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-291-1074
Practice Address - Fax:314-291-0802
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00215429OtherRAILROAD MEDICARE
MOH28400Medicare UPIN
MO032013572Medicare ID - Type Unspecified