Healthcare Provider Details

I. General information

NPI: 1306841473
Provider Name (Legal Business Name): MARK R LICHT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 S CHICKASAW TRL STE 202
ORLANDO FL
32825-3501
US

IV. Provider business mailing address

805 CENTURY MEDICAL DR STE C
TITUSVILLE FL
32796-2100
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-6865
  • Fax: 407-303-6537
Mailing address:
  • Phone: 321-268-6868
  • Fax: 321-267-2713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME68004
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: