MEDICARE: DR. TED WILLIS LEDET M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	G9144	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	340001471	OTHER	TX	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	123232401	OTHER	TX	TPI
2	000000GR74	OTHER	TX	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164537247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TED WILLIS LEDET M.D.

Provider Business Mailing Address
First Line	:	4848 NE STALLINGS DRIVE
Second Line	:	SUITE 106
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965
Country	:	US
Telephone Number	:	936-569-0304
Fax Number	:	936-552-0232

Provider Business Practice Location Address
First Line	:	4848 NE STALLINGS DR
Second Line	:	SUITE 106
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1239
Country	:	US
Telephone Number	:	936-569-0304
Fax Number	:	936-552-0232

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/01/2010

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Directions to “ DR. TED WILLIS LEDET M.D.” Practice Location

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