Provider Demographics
NPI:1508863648
Name:LIGHT, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
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 1:1108 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065
Mailing Address - Country:US
Mailing Address - Phone:502-513-5058
Mailing Address - Fax:502-513-5215
Practice Address - Street 1:1108 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065
Practice Address - Country:US
Practice Address - Phone:502-513-5058
Practice Address - Fax:502-513-5215
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056762A2084P0800X
KY363552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64038847Medicaid
IL2003610101AMedicaid
IL2003610101AMedicaid
H00141Medicare UPIN
KY64038847Medicaid