Provider Demographics
NPI:1275887309
Name:LEGG, TAMARA (OD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:LEGG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 SOUTHDALE SHOPPING CENTER
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-920-8607
Mailing Address - Fax:952-920-8762
Practice Address - Street 1:2195 SOUTHDALE SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-920-8607
Practice Address - Fax:952-920-8762
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3309152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist