Provider Demographics
NPI:1063589042
Name:LEDESMA, ERNEST RICHARD JR (PT)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:RICHARD
Last Name:LEDESMA
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 EISENHOWER DR
Mailing Address - Street 2:BLDG 1400 SUITE A
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-1600
Mailing Address - Country:US
Mailing Address - Phone:912-401-0443
Mailing Address - Fax:912-401-0445
Practice Address - Street 1:124 POST HOUSE TRL
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9624
Practice Address - Country:US
Practice Address - Phone:912-450-1468
Practice Address - Fax:912-450-1470
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBBNLOtherMEDICARE INDIVIDUAL #
GAPT003700OtherSTATE BOARD OF PT