Healthcare Provider Details

I. General information

NPI: 1154683043
Provider Name (Legal Business Name): DANIEL MICAH LICHTMANN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15004 INNOVATION DRIVE
SAN DIEGO CA
92128
US

IV. Provider business mailing address

15004 INNOVATION DRIVE
SAN DIEGO CA
92128
US

V. Phone/Fax

Practice location:
  • Phone: 858-605-7969
  • Fax: 858-605-7172
Mailing address:
  • Phone: 858-605-7969
  • Fax: 858-605-7172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA128188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: