Basic Information
| Provider Information | |||||||||
| NPI: | 1447341243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LITCHMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 EAST AVENUE | ||||||||
| Address2: | SUITE 3G | ||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038384034 | ||||||||
| FaxNumber: | 2038536361 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 EAST AVENUE | ||||||||
| Address2: | SUITE 3G | ||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038384034 | ||||||||
| FaxNumber: | 2038536361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 027828 | CT | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 001278284 | 05 | CT | MEDICAID |