Provider Demographics
NPI:1275716433
Name:MARTY R LEGGETT OD PA
Entity Type:Organization
Organization Name:MARTY R LEGGETT OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEGGETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:352-391-2967
Mailing Address - Street 1:P.O. BOX 490012
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-0012
Mailing Address - Country:US
Mailing Address - Phone:352-391-2967
Mailing Address - Fax:352-391-2967
Practice Address - Street 1:309 W MAIN ST.
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748
Practice Address - Country:US
Practice Address - Phone:352-391-2967
Practice Address - Fax:352-391-2967
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTY R. LEGGETT, O.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-11
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOC0002242152W00000X
FLOPC2242152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078819800Medicaid
FLK5189Medicare UPIN
FL078819800Medicaid