Provider Demographics
NPI:1245264209
Name:LIGHTBOURN, ANDREA CELESTE (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:CELESTE
Last Name:LIGHTBOURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:29600 NORTHWESTERN HWY
Mailing Address - Street 2:104
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1016
Mailing Address - Country:US
Mailing Address - Phone:248-258-2332
Mailing Address - Fax:248-327-6082
Practice Address - Street 1:29600 NORTHWESTERN HWY
Practice Address - Street 2:104
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1016
Practice Address - Country:US
Practice Address - Phone:248-258-2332
Practice Address - Fax:248-327-6082
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301048299207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4408457Medicaid
0N44020Medicare PIN
B43190Medicare UPIN