Provider Demographics
NPI:1689657009
Name:LEDBETTER, MONTY STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:MONTY
Middle Name:STEPHEN
Last Name:LEDBETTER
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1153 CENTRE ST
Mailing Address - Street 2:RADIOLOGY FAULKNER HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-732-8098
Mailing Address - Fax:617-525-7333
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:RADIOLOGY FAULKNER HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-732-8098
Practice Address - Fax:617-525-7333
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1548122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA154812OtherTUFTS HEALTH CARE
MAJ19662OtherBLUE CROSS BLUE SHIELD
MA3188221Medicaid
MAJ19662OtherBLUE CROSS BLUE SHIELD
G86701Medicare UPIN