Provider Demographics
NPI:1497753271
Name:LEDESMA, JACOB ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:LEDESMA
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 1:431 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04276-2100
Mailing Address - Country:US
Mailing Address - Phone:207-364-7831
Mailing Address - Fax:207-369-9467
Practice Address - Street 1:431 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-2100
Practice Address - Country:US
Practice Address - Phone:207-364-7831
Practice Address - Fax:207-369-9467
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015612207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM8888Medicare ID - Type Unspecified
H39317Medicare UPIN