Provider Demographics
NPI:1558337121
Name:LICHTENBERG, KRISTIN N (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:N
Last Name:LICHTENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:1291 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3476
Practice Address - Country:US
Practice Address - Phone:203-245-1413
Practice Address - Fax:860-358-8655
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008042879Medicaid
CTD400241263Medicare PIN