Healthcare Provider Details

I. General information

NPI: 1306948526
Provider Name (Legal Business Name): LEDRO JUSTICE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S 4TH ST
PHILADELPHIA PA
19147-5948
US

IV. Provider business mailing address

2023 PARKRIDGE DR
VAN BUREN AR
72956-7487
US

V. Phone/Fax

Practice location:
  • Phone: 479-629-0658
  • Fax:
Mailing address:
  • Phone: 479-629-0658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberR-4656
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: