Provider Demographics
NPI:1407381486
Name:LIGHTBOURNE, TABER CLOEY (MD)
Entity Type:Individual
Prefix:
First Name:TABER
Middle Name:CLOEY
Last Name:LIGHTBOURNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-7119
Mailing Address - Fax:215-662-7200
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-7119
Practice Address - Fax:215-662-7200
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4728832084P0800X
NY295917208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1407381486Medicaid
NY295917OtherNY OFFICE OF PROFESSIONS