Provider Demographics
NPI:1477552479
Name:LEDBETTER, MICHAEL H (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:H
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 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1930 N BUSINESS ROUTE 5
Practice Address - Street 2:UNIT 1A
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2659
Practice Address - Country:US
Practice Address - Phone:573-346-5624
Practice Address - Fax:573-346-1957
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9D86207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010010035OtherRAILROAD MEDICARE
MO241994201Medicaid
MO015013557Medicare PIN
MO241994201Medicaid