Provider Demographics
NPI:1700085784
Name:DIAZ LEDESMA, LIZETH (MD)
Entity type:Individual
Prefix:
First Name:LIZETH
Middle Name:
Last Name:DIAZ LEDESMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5339
Mailing Address - Country:US
Mailing Address - Phone:615-377-5651
Mailing Address - Fax:615-829-8513
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905
Practice Address - Country:US
Practice Address - Phone:607-798-5671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111187207R00000X
NY261666207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA03012782Medicaid
PA1022060610001Medicaid
FL004333300Medicaid
PA129174N8QMedicare PIN
PA03012782Medicaid