Provider Demographics
NPI:1104087311
Name:LIGHTBURN, NAOMI C (MD)
Entity type:Individual
Prefix:DR
First Name:NAOMI
Middle Name:C
Last Name:LIGHTBURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 N. UNIVERSITY BLVD
Practice Address - Street 2:UH1501
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-948-1310
Practice Address - Fax:317-962-0503
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069655A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INN/AMedicaid
IN201029150Medicaid
INM400068945Medicare PIN
INP01047441Medicare PIN
INM400064056Medicare PIN