Provider Demographics
NPI:1720392020
Name:LICHLYTER, CRAIG MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:MICHAEL
Last Name:LICHLYTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-1225
Mailing Address - Country:US
Mailing Address - Phone:260-347-3458
Mailing Address - Fax:260-347-4425
Practice Address - Street 1:781 E NORTH ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-1225
Practice Address - Country:US
Practice Address - Phone:260-347-3458
Practice Address - Fax:260-347-4425
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003657A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200992180Medicaid
IN200992180Medicaid