Provider Demographics
NPI:1083696637
Name:LIGHTFOOTE, JOHNSON BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNSON
Middle Name:BENJAMIN
Last Name:LIGHTFOOTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHNSON
Other - Middle Name:BENJAMIN
Other - Last Name:LIGHTFOOTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:808 S EASTHILLS DR
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-3449
Mailing Address - Country:US
Mailing Address - Phone:909-865-9535
Mailing Address - Fax:909-630-7394
Practice Address - Street 1:1798 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767
Practice Address - Country:US
Practice Address - Phone:909-865-9535
Practice Address - Fax:909-630-7394
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG394562085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 90724OtherSTATE MEDICAL LICENSE
NC200500078OtherSTATE MEDICAL LICENSE
CAG39456OtherSTATE MEDICAL LICENSE
ALAL 8043OtherSTATE MEDICAL LICENSE
NC200500078OtherSTATE MEDICAL LICENSE