Healthcare Provider Details

I. General information

NPI: 1699056309
Provider Name (Legal Business Name): LESLIE D REDDELL D.O,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 8TH AVE STE 306
FORT WORTH TX
76104-2602
US

IV. Provider business mailing address

PO BOX 865
FORT WORTH TX
76101-0865
US

V. Phone/Fax

Practice location:
  • Phone: 822-243-7486
  • Fax: 682-841-0039
Mailing address:
  • Phone: 817-632-1900
  • Fax: 817-632-1904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberP0783
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberP0783
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: