Provider Demographics
NPI:1053409847
Name:LICHTIGER, SIMON (MD)
Entity type:Individual
Prefix:MR
First Name:SIMON
Middle Name:
Last Name:LICHTIGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W 168TH ST
Mailing Address - Street 2:BOX 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-342-5155
Mailing Address - Fax:212-722-4703
Practice Address - Street 1:12 EAST 86 ST.
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-6849
Practice Address - Country:US
Practice Address - Phone:212-831-4900
Practice Address - Fax:212-722-4703
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146902207R00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNS4196OtherOXFORD
NYB14525Medicare UPIN
NYA400101542Medicare PIN