Provider Demographics
NPI:1063662526
Name:LEGASPI, MARY A (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:LEGASPI
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 1:33 OVERLOOK RD
Mailing Address - Street 2:STE L01
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3570
Mailing Address - Country:US
Mailing Address - Phone:908-522-5700
Mailing Address - Fax:908-273-8014
Practice Address - Street 1:33 OVERLOOK RD
Practice Address - Street 2:SUITE L01
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3570
Practice Address - Country:US
Practice Address - Phone:908-522-5700
Practice Address - Fax:908-273-8014
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA116589207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA116589OtherMEDICAL LICENSE