Provider Demographics
NPI:1295726560
Name:LIGHT, TIMOTHY D (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:LIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E BLOOMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-2803
Mailing Address - Country:US
Mailing Address - Phone:319-338-9247
Mailing Address - Fax:319-338-2785
Practice Address - Street 1:510 E BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-2803
Practice Address - Country:US
Practice Address - Phone:319-338-9247
Practice Address - Fax:319-338-2785
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD332922086S0102X
IA368932086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA27811OtherWELLMARK BCBS
IA0743179Medicaid
IA0743179Medicaid
IAI18631Medicare PIN
014708W15Medicare ID - Type Unspecified