Individual
DR. JENIFER R LIGHTDALE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
55 LAKE AVE N, WORCESTER, MA 01655-0002
(774) 441-8082
(774) 441-8056
Mailing address
PO BOX 415348, BOSTON, MA 02241-5348
(800) 225-8885
(508) 334-1977
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
208223
MA
2080P0206X
Pediatric Gastroenterology Physician
Primary
208223
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110005111A
—
MA
01
—
A3343901
MEDICARE
MA
Enumeration date
08/15/2006
Last updated
10/28/2020
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