Provider Demographics
NPI:1568623544
Name:LIGHT, MARTIN
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:LIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BRANCHPORT DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2902
Mailing Address - Country:US
Mailing Address - Phone:314-469-3484
Mailing Address - Fax:314-469-3484
Practice Address - Street 1:330 BRANCHPORT DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2902
Practice Address - Country:US
Practice Address - Phone:314-469-3484
Practice Address - Fax:314-469-3484
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor