Provider Demographics
NPI:1588742977
Name:LIGHTHOUSE INTERNAL MEDICINE AND PRIMARY CARE PA
Entity type:Organization
Organization Name:LIGHTHOUSE INTERNAL MEDICINE AND PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:CHONGLUN
Authorized Official - Middle Name:
Authorized Official - Last Name:XIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-636-9510
Mailing Address - Street 1:5757 BOOTH RD BLDG 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5981
Mailing Address - Country:US
Mailing Address - Phone:904-636-9510
Mailing Address - Fax:904-636-9512
Practice Address - Street 1:5757 BOOTH RD.
Practice Address - Street 2:#200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-636-9510
Practice Address - Fax:904-636-9512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009831900Medicaid
FL40311OtherBCBS FL
FL273938100Medicaid