Provider Demographics
NPI:1922083682
Name:LIGHTDALE, HALLIE (MD)
Entity Type:Individual
Prefix:
First Name:HALLIE
Middle Name:
Last Name:LIGHTDALE
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 1:2737 DEVONSHIRE PL NW
Mailing Address - Street 2:#123
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-3479
Mailing Address - Country:US
Mailing Address - Phone:718-637-7679
Mailing Address - Fax:
Practice Address - Street 1:2737 DEVONSHIRE PL NW
Practice Address - Street 2:#123
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-3479
Practice Address - Country:US
Practice Address - Phone:718-637-7679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC355582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15764Medicare UPIN