Healthcare Provider Details

I. General information

NPI: 1619137312
Provider Name (Legal Business Name): HARRELL LIGHTFOOT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E WENDOVER AVE STE 411
GREENSBORO NC
27401-1211
US

IV. Provider business mailing address

61 WHITCHER STREET SUITE 4100
MARIETTA GA
30060-1181
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number076489
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: