Healthcare Provider Details

I. General information

NPI: 1831727718
Provider Name (Legal Business Name): JEREMY GLYNN LIGHT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 PINEHURST DR
BRANSON MO
65616-2796
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 417-888-0858
  • Fax: 417-889-0476
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2023049376
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2023049376
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: