1659363331 NPI number — KAREN H LICKTEIG MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659363331 NPI number — KAREN H LICKTEIG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LICKTEIG
Provider First Name:
KAREN
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659363331
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1960 NW 167TH PL
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97006-4803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-531-2594
Provider Business Mailing Address Fax Number:
503-466-1399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 NW 22ND AVE
Provider Second Line Business Practice Location Address:
STE 320
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-2900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-295-2546
Provider Business Practice Location Address Fax Number:
503-790-1248
Provider Enumeration Date:
08/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD21058 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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