Provider Demographics
NPI:1669475273
Name:LICHT, AMNON (MD)
Entity Type:Individual
Prefix:DR
First Name:AMNON
Middle Name:
Last Name:LICHT
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 1:9808 VENICE BLVD
Mailing Address - Street 2:STE 706
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6827
Mailing Address - Country:US
Mailing Address - Phone:310-839-3200
Mailing Address - Fax:310-839-1247
Practice Address - Street 1:9808 VENICE BLVD
Practice Address - Street 2:STE 706
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6827
Practice Address - Country:US
Practice Address - Phone:310-839-3200
Practice Address - Fax:310-839-1247
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA032682207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA32682Medicare ID - Type Unspecified
CAB50202Medicare UPIN
CA00A326820Medicare ID - Type Unspecified