Provider Demographics
NPI:1821051020
Name:GOLIGHTLY, MARTY LYNN (IDC)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:LYNN
Last Name:GOLIGHTLY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39037 VIA LAS SINTRAS
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4323
Mailing Address - Country:US
Mailing Address - Phone:619-252-6131
Mailing Address - Fax:
Practice Address - Street 1:35000 GUADALCANAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-5599
Practice Address - Country:US
Practice Address - Phone:619-524-4043
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman