Provider Demographics
NPI:1265478598
Name:FREDHOLM, LEIGH ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:LEIGH
Middle Name:ANNE
Last Name:FREDHOLM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8107 SPRINGDALE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724-2437
Mailing Address - Country:US
Mailing Address - Phone:512-651-8644
Mailing Address - Fax:512-651-8635
Practice Address - Street 1:8107 SPRINGDALE RD STE 110
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78724-2437
Practice Address - Country:US
Practice Address - Phone:512-651-8644
Practice Address - Fax:512-651-8635
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4126207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135697410Medicaid
TX135697409Medicaid
TX8DL499OtherBCBS ID #
TXTXB161983Medicare PIN
TX135697410Medicaid
TX135697409Medicaid