Provider Demographics
NPI:1558334458
Name:LICHNOWSKI, KRZYSZTOF BOLESLAW (MD)
Entity Type:Individual
Prefix:DR
First Name:KRZYSZTOF
Middle Name:BOLESLAW
Last Name:LICHNOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 JACK MARTIN BLVD.
Mailing Address - Street 2:C-3
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3515
Mailing Address - Country:US
Mailing Address - Phone:732-840-8500
Mailing Address - Fax:732-840-7552
Practice Address - Street 1:204 JACK MARTIN BLVD
Practice Address - Street 2:C-3
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7770
Practice Address - Country:US
Practice Address - Phone:732-840-8500
Practice Address - Fax:732-840-7552
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA50509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ578530Medicare ID - Type Unspecified
NJE39074Medicare UPIN