Provider Demographics
NPI:1780620476
Name:LEDBETTER, SUSAN (DO)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:LEDBETTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 SE 5TH AVE #1113
Mailing Address - Street 2:
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:954-262-3753
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-4100
Practice Address - Fax:954-262-3753
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9002207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS 9002OtherSTATE LICENSE NUMBER
FLOS 9002OtherSTATE LICENSE NUMBER