Healthcare Provider Details

I. General information

NPI: 1821052028
Provider Name (Legal Business Name): MICHAEL J LEDDY III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 MASONIC DR
ALEXANDRIA LA
71301-3842
US

IV. Provider business mailing address

3444 MASONIC DR
ALEXANDRIA LA
71301-3615
US

V. Phone/Fax

Practice location:
  • Phone: 318-473-9556
  • Fax: 318-441-8339
Mailing address:
  • Phone: 318-473-9556
  • Fax: 318-441-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME0088196
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD.024005
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD024005
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: