Healthcare Provider Details

I. General information

NPI: 1063739266
Provider Name (Legal Business Name): JOHN LICHTSINN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7766 HIGHWAY 65 NE
SPRING LAKE PARK MN
55432-2832
US

IV. Provider business mailing address

7766 HIGHWAY 65 NE
SPRING LAKE PARK MN
55432-2832
US

V. Phone/Fax

Practice location:
  • Phone: 763-205-4843
  • Fax: 612-416-2085
Mailing address:
  • Phone: 763-205-4843
  • Fax: 612-416-2085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number55108
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: