Provider Demographics
NPI:1417903048
Name:LIGHTHOUSE INTERNAL MEDICINE P.A.
Entity Type:Organization
Organization Name:LIGHTHOUSE INTERNAL MEDICINE P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-422-5506
Mailing Address - Street 1:909 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1731
Mailing Address - Country:US
Mailing Address - Phone:302-422-5506
Mailing Address - Fax:302-422-5507
Practice Address - Street 1:909 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1731
Practice Address - Country:US
Practice Address - Phone:302-422-5506
Practice Address - Fax:302-422-5507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC100006175207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000036273OtherDELAWARE PHYSICIANS CARE
DEDD5833OtherRAIL ROAD MEDICARE
DE1000036273Medicaid
DE1000036273Medicaid