Provider Demographics
NPI:1649236423
Name:TICHANSKY, DAVID SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SAMUEL
Last Name:TICHANSKY
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLAZA SUITE 214
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-5563
Practice Address - Country:US
Practice Address - Phone:310-794-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066823L208600000X
TN38725208600000X
NJ25MA07587100208600000X
CAC190984208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022206230001Medicaid
NJ0177369Medicaid
SD3895577Medicaid
NJ0177369Medicaid
SD3895577Medicaid
SD3895577Medicaid