MEDICARE: DR. GARY D LICHTEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	35038945	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174517932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY D LICHTEN MD

Provider Business Mailing Address
First Line	:	3624 W MARKET ST
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-4510
Country	:	US
Telephone Number	:	330-665-0555
Fax Number	:	330-665-0556

Provider Business Practice Location Address
First Line	:	3624 W MARKET ST
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-4510
Country	:	US
Telephone Number	:	330-665-0555
Fax Number	:	330-665-0556

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	07/25/2016

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