Healthcare Provider Details

I. General information

NPI: 1285023309
Provider Name (Legal Business Name): LIGHTHOUSE PEDIATRICS OF NAPLES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3227 HORSESHOE DR S
NAPLES FL
34104-6114
US

IV. Provider business mailing address

3227 HORSESHOE DR S
NAPLES FL
34104-6114
US

V. Phone/Fax

Practice location:
  • Phone: 239-449-9882
  • Fax: 239-449-9884
Mailing address:
  • Phone: 239-449-9882
  • Fax: 239-449-9884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME076050
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME0053566
License Number StateFL

VIII. Authorized Official

Name: DR. DEBRA GOODRIDGE SHEPARD
Title or Position: DOCTOR/PRACTICE CO-OWNER
Credential: M.D.
Phone: 239-449-9882