Provider Demographics
NPI:1235190380
Name:LEDGERWOOD, GREG L (MD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:L
Last Name:LEDGERWOOD
Suffix:
Gender:M
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:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0337
Mailing Address - Country:US
Mailing Address - Phone:509-689-2525
Mailing Address - Fax:509-689-3247
Practice Address - Street 1:520 W INDIAN AVE
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812
Practice Address - Country:US
Practice Address - Phone:509-689-2525
Practice Address - Fax:509-689-3247
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012638207KI0005X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1003813Medicaid
202565OtherL&I
WA1003813Medicaid
A07275Medicare UPIN