1104865435 NPI number — JEFFERY D LIGHTFOOT PSYD

Table of content: JEFFERY D LIGHTFOOT PSYD (NPI 1104865435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104865435 NPI number — JEFFERY D LIGHTFOOT PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIGHTFOOT
Provider First Name:
JEFFERY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
M

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:
1104865435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 N MERIDIAN ST
Provider Second Line Business Mailing Address:
STE 114
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46204-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 COLD SPRING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46222-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-274-8660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2006

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: 103T00000X , with the licence number:  20041870 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200487810 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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