Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | G4483 | TX |
NPI | 1033112941 |
---|---|
Provider Name | Dr. Jon T Ledlie |
First Address | Tyler, TX 75701-1955 |
Second Address | Tyler, TX 75701-1955 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B24302 | (02) | TX |