Provider Demographics
NPI:1831727718
Name:LIGHT, JEREMY GLYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:GLYNN
Last Name:LIGHT
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-273-3376
Mailing Address - Fax:888-682-0525
Practice Address - Street 1:969 N MASON RD
Practice Address - Street 2:DIV IM DERMATOLOGY, STE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6282
Practice Address - Country:US
Practice Address - Phone:314-273-3376
Practice Address - Fax:888-682-0525
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023049376207N00000X
390200000X
MO2021014984390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200098794Medicaid