Provider Demographics
NPI:1013995687
Name:LEDESMA, DWAYNE FELIX (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:FELIX
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 1:8141 BELLARUS WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1783
Mailing Address - Country:US
Mailing Address - Phone:727-845-3555
Mailing Address - Fax:727-842-3556
Practice Address - Street 1:8141 BELLARUS WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1783
Practice Address - Country:US
Practice Address - Phone:727-845-3555
Practice Address - Fax:727-842-3556
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 80320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2504815OtherAETNA HMO
FL5519719OtherAETNA PPO
FL592523434OtherCIGNA, UNITED, GHI
FL266333300Medicaid
FL51708OtherBC/BS OF FL #
FL98621OtherBC/BS OF FL GROUP #
FL592523434OtherCIGNA, UNITED, GHI
FLK1298Medicare ID - Type UnspecifiedMEDICARE GROUP #
FL266333300Medicaid
FL51708OtherBC/BS OF FL #
FLG98828Medicare UPIN