Provider Demographics
NPI:1508056326
Name:LIGHTHOUSE FOOT & ANKLE CENTER
Entity Type:Organization
Organization Name:LIGHTHOUSE FOOT & ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLETTE
Authorized Official - Middle Name:TARA
Authorized Official - Last Name:D'ALTILIO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-933-9033
Mailing Address - Street 1:PO BOX 50163
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE PT
Mailing Address - State:FL
Mailing Address - Zip Code:33074-0163
Mailing Address - Country:US
Mailing Address - Phone:954-933-9033
Mailing Address - Fax:954-934-0060
Practice Address - Street 1:2100 NE 36TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:LIGHTHOUSE PT
Practice Address - State:FL
Practice Address - Zip Code:33064-7574
Practice Address - Country:US
Practice Address - Phone:954-933-9033
Practice Address - Fax:954-934-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3030213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6532Medicare PIN
FL5303140001Medicare NSC