Provider Demographics
NPI:1619112208
Name:JAMES M LIGHT MD PA
Entity Type:Organization
Organization Name:JAMES M LIGHT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-522-4485
Mailing Address - Street 1:940 42ND AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-4532
Mailing Address - Country:US
Mailing Address - Phone:727-522-4485
Mailing Address - Fax:727-520-9033
Practice Address - Street 1:2299 9TH AVE N
Practice Address - Street 2:SUITE1 A
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6800
Practice Address - Country:US
Practice Address - Phone:727-989-4458
Practice Address - Fax:727-321-7918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0025779261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058195000Medicaid
FL058195000Medicaid