1285023309 NPI number — LIGHTHOUSE PEDIATRICS OF NAPLES, LLC

Table of content: (NPI 1285023309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285023309 NPI number — LIGHTHOUSE PEDIATRICS OF NAPLES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE PEDIATRICS OF NAPLES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1285023309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3227 HORSESHOE DR S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34104-6114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-449-9882
Provider Business Mailing Address Fax Number:
239-449-9884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3227 HORSESHOE DR S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34104-6114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-449-9882
Provider Business Practice Location Address Fax Number:
239-449-9884
Provider Enumeration Date:
01/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPARD
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
GOODRIDGE
Authorized Official Title or Position:
DOCTOR/PRACTICE CO-OWNER
Authorized Official Telephone Number:
239-449-9882

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  ME0053566 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: ME076050 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07336 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 254504700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43843 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 048604300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043264302 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1619918711 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 014154300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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