MEDICARE: DR. MARK R LICHT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	ME68004	FL
2	208800000X	Urology Physician	ME68004	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306841473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK R LICHT M.D.

Provider Business Mailing Address
First Line	:	805 CENTURY MEDICAL DR STE C
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32796-2100
Country	:	US
Telephone Number	:	321-268-6868
Fax Number	:	321-267-2713

Provider Business Practice Location Address
First Line	:	258 S CHICKASAW TRL STE 202
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-3501
Country	:	US
Telephone Number	:	407-303-6865
Fax Number	:	407-303-6537

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	04/29/2025

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