Healthcare Provider Details

I. General information

NPI: 1598880577
Provider Name (Legal Business Name): GREGG ALAN LICHTENSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 CAMPANILE DR STUDENT HEALTH SERVICES SAN DIEGO STATE UNIVERSITY
SAN DIEGO CA
92182-0001
US

IV. Provider business mailing address

STUDENT HEALTH SERVICES, SAN DIEGO STATE UNIVERSITY 5500 CAMPANILE DRIVE
SAN DIEGO CA
92182-4701
US

V. Phone/Fax

Practice location:
  • Phone: 619-594-5281
  • Fax: 619-594-3638
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG44467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: