Provider Demographics
NPI:1578900353
Name:DOUGLAS J LICHTI MD PC
Entity Type:Organization
Organization Name:DOUGLAS J LICHTI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LICHTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-657-2711
Mailing Address - Street 1:380 E 1500 S
Mailing Address - Street 2:STE 201
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3940
Mailing Address - Country:US
Mailing Address - Phone:435-657-2711
Mailing Address - Fax:435-657-2716
Practice Address - Street 1:380 E 1500 S
Practice Address - Street 2:STE 201
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3940
Practice Address - Country:US
Practice Address - Phone:435-657-2711
Practice Address - Fax:435-657-2716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1835651205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10/27/1955OtherOWNERS DOB