Provider Demographics
NPI:1841267457
Name:LICHT, PETER D (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:D
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 1:172 MOUNT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-1443
Mailing Address - Country:US
Mailing Address - Phone:203-426-8442
Mailing Address - Fax:203-270-7464
Practice Address - Street 1:172 MOUNT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1443
Practice Address - Country:US
Practice Address - Phone:203-426-8442
Practice Address - Fax:203-270-7464
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017612207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001176122Medicaid
110227989OtherRAILROAD MEDICARE
CTC64990Medicare UPIN
110227989OtherRAILROAD MEDICARE