Provider Demographics
NPI:1427149764
Name:LICHTENFELD, MARK ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:LICHTENFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:358 LITTANY LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2308
Mailing Address - Country:US
Mailing Address - Phone:314-434-8666
Mailing Address - Fax:
Practice Address - Street 1:14748 MANCHESTER RD # B
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3706
Practice Address - Country:US
Practice Address - Phone:636-256-3636
Practice Address - Fax:636-256-8734
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36554207Q00000X
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5966114OtherAETNA PROVIDER #
MO100939OtherHEALTHLINK PROVIDER NUMBE
MO5966114OtherAETNA PROVIDER #