Provider Demographics
NPI:1679569669
Name:LICHTENSTEIN, MITCHELL K (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:K
Last Name:LICHTENSTEIN
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 1:9700 KENTON AVE
Mailing Address - Street 2:SUITE #302
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1259
Mailing Address - Country:US
Mailing Address - Phone:847-674-2097
Mailing Address - Fax:847-674-2096
Practice Address - Street 1:9700 KENTON AVE
Practice Address - Street 2:SUITE #302
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1259
Practice Address - Country:US
Practice Address - Phone:847-674-2097
Practice Address - Fax:847-674-2096
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE33798Medicare UPIN
ILL89955Medicare ID - Type Unspecified