Provider Demographics
NPI:1942252069
Name:LICHTBLAU, CRAIG H (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:H
Last Name:LICHTBLAU
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 1:550 NORTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-5409
Mailing Address - Country:US
Mailing Address - Phone:561-842-3694
Mailing Address - Fax:561-842-3774
Practice Address - Street 1:550 NORTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-5409
Practice Address - Country:US
Practice Address - Phone:561-842-3694
Practice Address - Fax:561-842-3774
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056279208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039775000Medicaid
FL08821ZMedicare ID - Type Unspecified
FLE22630Medicare UPIN