Provider Demographics
NPI:1861496705
Name:LICHTENBERG, RICHARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:LICHTENBERG
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 1:1999 SPROUL RD
Mailing Address - Street 2:STE 21
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3508
Mailing Address - Country:US
Mailing Address - Phone:610-353-6400
Mailing Address - Fax:610-356-1204
Practice Address - Street 1:1999 SPROUL RD
Practice Address - Street 2:STE 21
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3508
Practice Address - Country:US
Practice Address - Phone:610-353-6400
Practice Address - Fax:610-356-1204
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018781E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA131926OtherBLUE SHIELD
PA0007336900002Medicaid
PA0031373000OtherKEYSTONE
PA58229OtherAETNA
PACF6196OtherRAILROAD MEDICARE
PA131926OtherBLUE SHIELD
PAC30463Medicare UPIN