Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | MD068489L | PA |
Y | 2084N0402X | Child Neurologist | MD068489L | PA |
NPI | 1023032539 |
---|---|
Provider Name | Daniel J Licht |
First Address | Philadelphia, PA 19107-3323 |
Second Address | Philadelphia, PA 19104-4319 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 23/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001895942 | (05) | PA |
8852804 | (05) | NJ |
H61634 | (02) |