Healthcare Provider Details

I. General information

NPI: 1043630353
Provider Name (Legal Business Name): LIGHTHOUSE PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 04/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHETSTONE PL SUITE 211
ST AUGUSTINE FL
32086-5774
US

IV. Provider business mailing address

100 WHETSTONE PL SUITE 211
ST AUGUSTINE FL
32086-5774
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-7648
  • Fax: 904-342-8567
Mailing address:
  • Phone: 904-342-7648
  • Fax: 904-342-8567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME90727
License Number StateFL

VIII. Authorized Official

Name: VINCENT LUZ
Title or Position: OWNER
Credential: MD
Phone: 904-342-7648