Provider Demographics
NPI:1871917302
Name:LEDEZMA, LUIS A (LMT)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:A
Last Name:LEDEZMA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 STATE HIGHWAY 47
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-5931
Mailing Address - Country:US
Mailing Address - Phone:505-510-1621
Mailing Address - Fax:505-861-0598
Practice Address - Street 1:315 W REINKEN AVE
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-4256
Practice Address - Country:US
Practice Address - Phone:505-510-1621
Practice Address - Fax:505-861-0598
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7785171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor