Provider Demographics
NPI:1669806576
Name:LEDEZMA, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LEDEZMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:O
Other - Last Name:LEDEZMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RNFA
Mailing Address - Street 1:PO BOX 430651
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92143-0651
Mailing Address - Country:US
Mailing Address - Phone:619-395-4808
Mailing Address - Fax:
Practice Address - Street 1:3003 HEALTH CENTER DR
Practice Address - Street 2:THIRD FLOOR-OR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2700
Practice Address - Country:US
Practice Address - Phone:858-939-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 762200390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program