Provider Demographics
NPI:1427131226
Name:LICHT, MYRON B (DO)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:B
Last Name:LICHT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2100
Mailing Address - Country:US
Mailing Address - Phone:541-269-0333
Mailing Address - Fax:
Practice Address - Street 1:1750 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2100
Practice Address - Country:US
Practice Address - Phone:541-269-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO158099207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151994Medicaid
ORE45928Medicare UPIN
ORZ24448Medicare PIN