Provider Demographics
NPI:1134409097
Name:LEA, MICHAEL LUDWELL (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LUDWELL
Last Name:LEA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E LOS EBANOS BLVD
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8481
Mailing Address - Country:US
Mailing Address - Phone:956-546-3116
Mailing Address - Fax:956-546-8793
Practice Address - Street 1:425 E LOS EBANOS BLVD
Practice Address - Street 2:SUITE 100B
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8481
Practice Address - Country:US
Practice Address - Phone:956-546-3116
Practice Address - Fax:956-546-8793
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1199702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308952601Medicaid
TXB164258Medicare PIN