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General NPI Number Information
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NPI Number | 1588742977
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE INTERNAL MEDICINE AND PRIMARY CARE PA
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 09/21/2018
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Provider Practice Location Address
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Address Line | 5757 BOOTH RD. #200
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City | JACKSONVILLE
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State | FL
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Zip | 32207
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Country | US
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Telephone | 904-636-9510
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Fax | 904-636-9512
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Provider Business Mailing Address
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Address Line | 5757 BOOTH RD BLDG 200
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City | JACKSONVILLE
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State | FL
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Zip | 32207-5981
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Country | US
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Telephone | 904-636-9510
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Fax | 904-636-9512
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Authorized Official
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Title or Position | MD
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Name | CHONGLUN XIE
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Credential |
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Telephone | 904-636-9510
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME92689
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License Number State | FL
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