Basic Information
Provider Information | |||||||||
NPI: | 1174627699 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRIDELBAUGH | ||||||||
FirstName: | LEANN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7547 GREENBRIER DR | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752254514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146925361 | ||||||||
FaxNumber: | 2144566819 | ||||||||
Practice Location | |||||||||
Address1: | 2750 W. NORTHWEST HWY | ||||||||
Address2: | SUITE 170 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752204783 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146540007 | ||||||||
FaxNumber: | 2146549272 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 08/03/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | J8629 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 139112019 | 05 | TX |   | MEDICAID | 139112021 | 05 | TX |   | MEDICAID | 176920001 | 01 | TX | TPI | OTHER | 139112017 | 05 | TX |   | MEDICAID | 139112026 | 05 | TX |   | MEDICAID | 139112020 | 05 | TX |   | MEDICAID |