Provider Demographics
NPI:1649281965
Name:LICHTSZTRAL, REGINA (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:LICHTSZTRAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 BROADWAY
Mailing Address - Street 2:ROOM E1-18
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-4952
Mailing Address - Fax:718-334-4815
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:ROOM E1-18
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-4952
Practice Address - Fax:718-334-4815
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1587412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01839110Medicaid
NY01839110Medicaid
NY5284VSMedicare PIN