Provider Demographics
NPI:1831185651
Name:LIGHT, DIANE LOUISE (DO)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LOUISE
Last Name:LIGHT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1125 MADISON ST
Mailing Address - Street 2:PO BOX 1107
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5227
Mailing Address - Country:US
Mailing Address - Phone:573-632-5700
Mailing Address - Fax:573-632-5720
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5700
Practice Address - Fax:573-632-5720
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO100575208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO020038004OtherRAILROAD MEDICARE
MO243392222Medicaid
MOE50134Medicare UPIN
MO024010669Medicare ID - Type Unspecified