MEDICARE: DR. LESLIE D REDDELL D.O,

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	208600000X	Surgery Physician	P0783	TX
2	2086S0127X	Trauma Surgery Physician	P0783	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P0783	OTHER	TX	TEXAS

General Provider Information

NPI Number	:	1699056309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE D REDDELL D.O,

Provider Business Mailing Address
First Line	:	PO BOX 865
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76101-0865
Country	:	US
Telephone Number	:	817-632-1900
Fax Number	:	817-632-1904

Provider Business Practice Location Address
First Line	:	800 8TH AVE STE 306
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2602
Country	:	US
Telephone Number	:	822-243-7486
Fax Number	:	682-841-0039

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

Provider Enumeration Date	:	09/08/2011
Last Update Date	:	07/08/2025

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