Healthcare Provider Details

I. General information

NPI: 1720158116
Provider Name (Legal Business Name): JONATHAN LICHT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100214 LURIE 5-123
GAINESVILLE FL
32610-0214
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7832
  • Fax: 352-273-6867
Mailing address:
  • Phone: 352-273-7832
  • Fax: 352-273-6867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number36116430
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME126669
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: