=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750355004
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN D LEDBETTER D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2006
-----------------------------------------------------
Last Update Date | 11/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1303 MCCULLOUGH AVE STE 135
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78212-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-227-9214
-----------------------------------------------------
Fax | 210-476-8515
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1303 MCCULLOUGH AVE STE 135
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78212-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-227-9214
-----------------------------------------------------
Fax | 210-476-8515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | K5598
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------