Provider Demographics
NPI:1811218233
Name:LIGHTBOURNE, MARISSA (MD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:LIGHTBOURNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:UHC 5C
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-577-4342
Mailing Address - Fax:313-745-4707
Practice Address - Street 1:50 E CANFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1804
Practice Address - Country:US
Practice Address - Phone:313-745-6960
Practice Address - Fax:313-966-7305
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096541207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics