Healthcare Provider Details

I. General information

NPI: 1659363331
Provider Name (Legal Business Name): KAREN H LICKTEIG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 NW 22ND AVE STE 320
PORTLAND OR
97210-2900
US

IV. Provider business mailing address

1960 NW 167TH PL STE 200
BEAVERTON OR
97006-4803
US

V. Phone/Fax

Practice location:
  • Phone: 503-295-2546
  • Fax: 503-790-1248
Mailing address:
  • Phone: 503-531-2594
  • Fax: 503-466-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD21058
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: