MEDICARE: LIGHTHOUSE PEDIATRICS OF NAPLES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	ME0053566	FL
2	208000000X	Pediatrics Physician	ME076050	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	07336	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	43843	OTHER	FL	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	1043264302	OTHER		INDIVIDUAL NPI
6	1619918711	OTHER		INDIVIDUAL NPI
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285023309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE PEDIATRICS OF NAPLES, LLC

Provider Business Mailing Address
First Line	:	3227 HORSESHOE DR S
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34104-6114
Country	:	US
Telephone Number	:	239-449-9882
Fax Number	:	239-449-9884

Provider Business Practice Location Address
First Line	:	3227 HORSESHOE DR S
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34104-6114
Country	:	US
Telephone Number	:	239-449-9882
Fax Number	:	239-449-9884

Authorized Official
Title or Position	:	DOCTOR/PRACTICE CO-OWNER
Name	:	DR. DEBRA GOODRIDGE SHEPARD
Credential	:	M.D.
Telephone Number	:	239-449-9882

Provider Enumeration Date	:	01/13/2015
Last Update Date	:	01/13/2015

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Directions to “LIGHTHOUSE PEDIATRICS OF NAPLES, LLC ” Practice Location

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