Provider Demographics
NPI:1174627699
Name:KRIDELBAUGH, LEANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LEANN
Middle Name:
Last Name:KRIDELBAUGH
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 1:7547 GREENBRIER DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-4514
Mailing Address - Country:US
Mailing Address - Phone:214-692-5361
Mailing Address - Fax:214-456-6819
Practice Address - Street 1:2750 W. NORTHWEST HWY
Practice Address - Street 2:SUITE 170
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-4783
Practice Address - Country:US
Practice Address - Phone:214-654-0007
Practice Address - Fax:214-654-9272
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8629208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139112019Medicaid
TX139112021Medicaid
TX176920001OtherTPI
TX139112017Medicaid
TX139112026Medicaid
TX139112020Medicaid
TX139112026Medicaid