Provider Demographics
NPI:1427055805
Name:LIGHT, MARK R (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:LIGHT
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:4439 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6452
Mailing Address - Country:US
Mailing Address - Phone:770-977-8221
Mailing Address - Fax:770-977-8222
Practice Address - Street 1:4439 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6452
Practice Address - Country:US
Practice Address - Phone:770-977-8221
Practice Address - Fax:770-977-8222
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA00630213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000467618BMedicaid
GA3026473OtherAETNA HMO
GA005480OtherBCBS
GA4137290OtherAETNA PPO
GA480034802OtherRAILROAD MEDICARE
GA4830810001OtherDMERC
GA412063128OtherTAX ID #
GAREF000049272OtherPEACHCARE MEDICARE
GA480034802OtherRAILROAD MEDICARE
GA000467618BMedicaid