Provider Demographics
NPI:1518260512
Name:MARK LICHTENBERG, MD
Entity Type:Organization
Organization Name:MARK LICHTENBERG, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:P
Authorized Official - Last Name:CERVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-926-6151
Mailing Address - Street 1:55 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1426
Mailing Address - Country:US
Mailing Address - Phone:201-926-6151
Mailing Address - Fax:509-463-9780
Practice Address - Street 1:55 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1426
Practice Address - Country:US
Practice Address - Phone:201-926-6151
Practice Address - Fax:509-463-9780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherBLUE CROSS BLUE SHIELD