Provider Demographics
NPI:1497147680
Name:LICHT, JOSEPH LEWIS (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LEWIS
Last Name:LICHT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3252 MAGNOLIA LANDING LN
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917-7807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2955 BROWNWOOD BLVD STE 303
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163-2040
Practice Address - Country:US
Practice Address - Phone:352-350-8484
Practice Address - Fax:352-751-9850
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16173207WX0200X, 207W00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112937700Medicaid