Provider Demographics
NPI:1770642274
Name:LICHT, JEFFREY HAMILTON (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:HAMILTON
Last Name:LICHT
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 1:315 HOLTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3254
Mailing Address - Country:US
Mailing Address - Phone:509-248-6292
Mailing Address - Fax:509-248-9134
Practice Address - Street 1:315 HOLTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3254
Practice Address - Country:US
Practice Address - Phone:509-248-6292
Practice Address - Fax:509-248-9134
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0021581207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1301506Medicaid
WA1301506Medicaid
8855326Medicare ID - Type Unspecified