Individual
DR. MARK R. LIGHT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
4439 ROSWELL RD, MARIETTA, GA 30062-6452
(770) 977-8221
(770) 977-8222
Mailing address
4439 ROSWELL RD, MARIETTA, GA 30062-6452
(770) 977-8221
(770) 977-8222
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
00630
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000467618B
—
GA
01
—
005480
BCBS
GA
01
—
3026473
AETNA HMO
GA
01
—
412063128
TAX ID #
GA
01
—
4137290
AETNA PPO
GA
01
—
480034802
RAILROAD MEDICARE
GA
01
—
4830810001
DMERC
GA
01
—
REF000049272
PEACHCARE MEDICARE
GA
Enumeration date
06/30/2005
Last updated
09/13/2016
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