Provider Demographics
NPI:1730237769
Name:MANGUBAT, LEDESMA (MD)
Entity type:Individual
Prefix:
First Name:LEDESMA
Middle Name:
Last Name:MANGUBAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEDESMA
Other - Middle Name:LIMBO
Other - Last Name:DE ROSALES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:400 CRAVEN RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4201
Mailing Address - Country:US
Mailing Address - Phone:800-290-5000
Mailing Address - Fax:760-510-5603
Practice Address - Street 1:400 CRAVEN RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4201
Practice Address - Country:US
Practice Address - Phone:619-528-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ASSIGNEDMedicare UPIN