Healthcare Provider Details

I. General information

NPI: 1043288087
Provider Name (Legal Business Name): JACK R LICHTENSTEIN, MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 RIDGELY AVE
ANNAPOLIS MD
21401
US

IV. Provider business mailing address

205 RIDGELY AVE
ANNAPOLIS MD
21401
US

V. Phone/Fax

Practice location:
  • Phone: 410-263-6910
  • Fax: 443-433-0456
Mailing address:
  • Phone: 410-263-6910
  • Fax: 443-433-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD08194
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberD08194
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberD0065841
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberD0008194
License Number StateMD

VIII. Authorized Official

Name: MR. JACK R. LICHTENSTEIN
Title or Position: OWNER
Credential: M.D.
Phone: 410-268-6910