Provider Demographics
NPI:1487650693
Name:LITCHMAN, CHARISSE D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARISSE
Middle Name:D
Last Name:LITCHMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5360
Mailing Address - Country:US
Mailing Address - Phone:203-969-7662
Mailing Address - Fax:203-969-0809
Practice Address - Street 1:1290 SUMMER ST
Practice Address - Street 2:5200
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5360
Practice Address - Country:US
Practice Address - Phone:203-969-7662
Practice Address - Fax:203-969-0809
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0323322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1300000406Medicare ID - Type Unspecified
F44043Medicare UPIN