Healthcare Provider Details

I. General information

NPI: 1275582132
Provider Name (Legal Business Name): CHRISTOPHER S LICHTENWALTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10238 E HAMPTON AVE SUITE 501
MESA AZ
85209-3316
US

IV. Provider business mailing address

10238 E HAMPTON AVE SUITE 501
MESA AZ
85209-3316
US

V. Phone/Fax

Practice location:
  • Phone: 480-889-1573
  • Fax: 480-889-1574
Mailing address:
  • Phone: 480-889-1573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number43102
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier526239
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: