Provider Demographics
NPI:1922213388
Name:GARY D LICHTEN MD INC
Entity Type:Organization
Organization Name:GARY D LICHTEN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LICHTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-253-7164
Mailing Address - Street 1:157 W CEDAR ST
Mailing Address - Street 2:STE. 201
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-2564
Mailing Address - Country:US
Mailing Address - Phone:330-253-7164
Mailing Address - Fax:330-434-3376
Practice Address - Street 1:157 W CEDAR ST
Practice Address - Street 2:STE. 201
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2564
Practice Address - Country:US
Practice Address - Phone:330-253-7164
Practice Address - Fax:330-434-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35038945174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0368963Medicaid
OHLI0444202Medicare ID - Type Unspecified
OHA77451Medicare UPIN