Provider Demographics
NPI:1285023309
Name:LIGHTHOUSE PEDIATRICS OF NAPLES, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE PEDIATRICS OF NAPLES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/PRACTICE CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:GOODRIDGE
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-449-9882
Mailing Address - Street 1:3227 HORSESHOE DR S
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34104-6114
Mailing Address - Country:US
Mailing Address - Phone:239-449-9882
Mailing Address - Fax:239-449-9884
Practice Address - Street 1:3227 HORSESHOE DR S
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34104-6114
Practice Address - Country:US
Practice Address - Phone:239-449-9882
Practice Address - Fax:239-449-9884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME076050208000000X
FLME00535662080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07336OtherBCBS
FL254504700Medicaid
FL43843OtherBCBS
FL048604300Medicaid
1043264302OtherINDIVIDUAL NPI
1619918711OtherINDIVIDUAL NPI
FL048604300Medicaid
D21205Medicare UPIN