Provider Demographics
NPI:1033112941
Name:LEDLIE, JON T (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:T
Last Name:LEDLIE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:700 OLYMPIC PLAZA CIR
Mailing Address - Street 2:STE 850
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1955
Mailing Address - Country:US
Mailing Address - Phone:903-595-2441
Mailing Address - Fax:903-595-0743
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:STE 850
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1955
Practice Address - Country:US
Practice Address - Phone:903-595-2441
Practice Address - Fax:903-595-0743
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG4483207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB24302Medicare UPIN
TX87A598Medicare ID - Type Unspecified