Provider Demographics
NPI:1376513176
Name:LIGHT, JIMMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:LIGHT
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 1:4204 ROSEMARY ST
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-5218
Mailing Address - Country:US
Mailing Address - Phone:301-657-3113
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:SUITE 3D - 31
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:202-877-6029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD25560204F00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC007305818Medicaid
DC025597100Medicaid
DC327801200Medicaid
DC327801200Medicaid
DC025597100Medicaid
DC432107T97Medicare ID - Type UnspecifiedTRAILBLAZER