Provider Demographics
NPI:1104900919
Name:LIGHT, KENNETH IAN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:IAN
Last Name:LIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13847 E 14TH ST STE 118
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2625
Mailing Address - Country:US
Mailing Address - Phone:415-673-4500
Mailing Address - Fax:
Practice Address - Street 1:1700 CALIFORNIA ST
Practice Address - Street 2:SUITE 340
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4586
Practice Address - Country:US
Practice Address - Phone:415-673-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
G35263174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46283Medicare UPIN