Provider Demographics
NPI:1043630353
Name:LIGHTHOUSE PEDIATRICS PLLC
Entity type:Organization
Organization Name:LIGHTHOUSE PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:LUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-342-7648
Mailing Address - Street 1:100 WHETSTONE PL
Mailing Address - Street 2:SUITE 211
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5774
Mailing Address - Country:US
Mailing Address - Phone:904-342-7648
Mailing Address - Fax:904-342-8567
Practice Address - Street 1:100 WHETSTONE PL
Practice Address - Street 2:SUITE 211
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5774
Practice Address - Country:US
Practice Address - Phone:904-342-7648
Practice Address - Fax:904-342-8567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90727208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty