Provider Demographics
NPI:1306191028
Name:TIMOTHY L. LIGHT D.O., P.A.
Entity Type:Organization
Organization Name:TIMOTHY L. LIGHT D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-584-8777
Mailing Address - Street 1:1573 S FORT HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-2004
Mailing Address - Country:US
Mailing Address - Phone:727-584-8777
Mailing Address - Fax:727-216-6117
Practice Address - Street 1:1573 S FORT HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-2004
Practice Address - Country:US
Practice Address - Phone:727-584-8777
Practice Address - Fax:727-216-6117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty