Provider Demographics
NPI:1205848272
Name:LIGHTFOOT, HARRY M (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:M
Last Name:LIGHTFOOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 HOSPITAL SOUTH DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6810
Mailing Address - Country:US
Mailing Address - Phone:770-944-7818
Mailing Address - Fax:
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:SUITE 202
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-944-7818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201117174400000X
NC2002-01117208600000X
GA200201117208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC200201117OtherNC LICENSE NUMBER
NC200201117OtherNC LICENSE NUMBER