1972562064 NPI number — MR. BUFORD BROWN LEDBETTER JR. MD

Table of content: MR. BUFORD BROWN LEDBETTER JR. MD (NPI 1972562064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972562064 NPI number — MR. BUFORD BROWN LEDBETTER JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEDBETTER
Provider First Name:
BUFORD
Provider Middle Name:
BROWN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972562064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
331 LANDRUM PL
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
CLARKSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37043-6329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-645-4200
Provider Business Mailing Address Fax Number:
931-645-4285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1731 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-645-4200
Provider Business Practice Location Address Fax Number:
931-645-4285
Provider Enumeration Date:
03/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  MD9047 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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