Provider Demographics
NPI:1346237120
Name:LEDBETTER, CARL E (DO)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:E
Last Name:LEDBETTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-1182
Mailing Address - Country:US
Mailing Address - Phone:816-630-6081
Mailing Address - Fax:816-629-3661
Practice Address - Street 1:1700 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-1182
Practice Address - Country:US
Practice Address - Phone:816-630-6081
Practice Address - Fax:816-629-3661
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241820745Medicaid
MO241820745Medicaid
MOH866359Medicare PIN