Provider Demographics
NPI:1861657736
Name:LEE RAYMOND LIGHT MD PA
Entity Type:Organization
Organization Name:LEE RAYMOND LIGHT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-262-1833
Mailing Address - Street 1:10971 BONITA BEACH RD
Mailing Address - Street 2:STE 1
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-9033
Mailing Address - Country:US
Mailing Address - Phone:239-262-1833
Mailing Address - Fax:239-262-3097
Practice Address - Street 1:10971 BONITA BEACH RD
Practice Address - Street 2:STE 1
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-9033
Practice Address - Country:US
Practice Address - Phone:239-262-1833
Practice Address - Fax:239-262-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAM045Medicare PIN
D57998Medicare UPIN