Provider Demographics
NPI:1598880577
Name:LICHTENSTEIN, GREGG ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ALAN
Last Name:LICHTENSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:STUDENT HEALTH SERVICES, SAN DIEGO STATE UNIVERSITY
Mailing Address - Street 2:5500 CAMPANILE DRIVE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92182-4701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5500 CAMPANILE DR
Practice Address - Street 2:STUDENT HEALTH SERVICES SAN DIEGO STATE UNIVERSITY
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92182-0001
Practice Address - Country:US
Practice Address - Phone:619-594-5281
Practice Address - Fax:619-594-3638
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG44467207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine