Provider Demographics
NPI:1730274317
Name:LIGHTBOURN, SUSAN ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:LIGHTBOURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:203 ROYALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EBENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15931
Mailing Address - Country:US
Mailing Address - Phone:814-472-7350
Mailing Address - Fax:814-472-8624
Practice Address - Street 1:4501 ADMIRAL PEARY HIGHWAY
Practice Address - Street 2:
Practice Address - City:EBENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15931
Practice Address - Country:US
Practice Address - Phone:814-472-7350
Practice Address - Fax:814-472-8624
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034281E207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA481333Medicare ID - Type Unspecified
PAF48834Medicare UPIN