Healthcare Provider Details

I. General information

NPI: 1427004647
Provider Name (Legal Business Name): WILLIAM LIGHTHART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE
JACKSON WY
83001-8640
US

IV. Provider business mailing address

PO BOX 10490
JACKSON WY
83002-0490
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-3900
  • Fax: 307-732-0925
Mailing address:
  • Phone: 307-733-3900
  • Fax: 307-732-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number036115858
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: