Healthcare Provider Details

I. General information

NPI: 1780992396
Provider Name (Legal Business Name): BENJAMIN L LIECHTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

550 FIRST AVENUE
NEW YORK NY
10016
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-2700
  • Fax:
Mailing address:
  • Phone: 302-545-6078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number294867
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: