Provider Demographics
NPI:1164492567
Name:LEDBETTER, MARCIALEE (MD)
Entity Type:Individual
Prefix:
First Name:MARCIALEE
Middle Name:
Last Name:LEDBETTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5148 N ASHLAND AVE # 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2830
Mailing Address - Country:US
Mailing Address - Phone:918-995-0584
Mailing Address - Fax:918-660-3631
Practice Address - Street 1:25 JUNE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2621
Practice Address - Country:US
Practice Address - Phone:207-324-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360843462084P0804X
OK202072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10023880DMedicaid
OK10023880DMedicaid
242412204Medicare ID - Type Unspecified