Basic Information
| Provider Information | |||||||||
| NPI: | 1801181581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEDESMA | ||||||||
| FirstName: | LINDA-MICHELLE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 S CLEARVIEW AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852093378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809889108 | ||||||||
| FaxNumber: | 4808134460 | ||||||||
| Practice Location | |||||||||
| Address1: | 3328 N LITCHFIELD RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853953198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232390394 | ||||||||
| FaxNumber: | 6235365813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2011 | ||||||||
| LastUpdateDate: | 11/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 006241 | AZ | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 859045 | 05 | AZ | MEDICAID |