Basic Information
Provider Information | |||||||||
NPI: | 1861479594 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LICHTENSTEIN | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 850 HARRISON AVE | ||||||||
Address2: | YACC BN-C7 | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021184001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 830 HARRISON AVE | ||||||||
Address2: | MOAKLEY, 2ND FLOOR | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021182905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6176386525 | ||||||||
FaxNumber: | 6176387448 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/23/2005 | ||||||||
LastUpdateDate: | 11/08/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 59979 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | 59979 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 110052964A | 05 | MA |   | MEDICAID |