Provider Demographics
NPI:1760463632
Name:LIGHT, BENJAMIN W (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:W
Last Name:LIGHT
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 13TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4307
Mailing Address - Country:US
Mailing Address - Phone:256-355-6200
Mailing Address - Fax:256-355-6241
Practice Address - Street 1:1218 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4307
Practice Address - Country:US
Practice Address - Phone:256-355-6200
Practice Address - Fax:256-355-6241
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00024976207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051512384Medicaid
AL515-12384OtherBCBS
ALCM6320OtherRAILROAD MEDICARE
ALP00017388OtherRAILROAD MEDICARE
AL051512384OtherPROVIDER NUMBER
AL051512384Medicare ID - Type UnspecifiedPROVIDER NUMBER
ALH21368Medicare UPIN