Provider Demographics
NPI:1750937389
Name:LEDESMA, AMADEO ESEQUIEL (PT)
Entity type:Individual
Prefix:
First Name:AMADEO
Middle Name:ESEQUIEL
Last Name:LEDESMA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:AJ
Other - Middle Name:
Other - Last Name:LEDESMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-8008
Mailing Address - Fax:
Practice Address - Street 1:6017 HILLSIDE RD STE 1100
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-7213
Practice Address - Country:US
Practice Address - Phone:806-680-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1321266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX403493601Medicaid
TX8LN865OtherBCBS