Provider Demographics
NPI:1306025630
Name:LEGGETT, DERRELL LEVOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRELL
Middle Name:LEVOHN
Last Name:LEGGETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:794 MCDONOUGH RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1572
Mailing Address - Country:US
Mailing Address - Phone:470-251-5300
Mailing Address - Fax:470-251-5301
Practice Address - Street 1:794 MCDONOUGH RD
Practice Address - Street 2:SUITE 108
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1572
Practice Address - Country:US
Practice Address - Phone:470-251-5300
Practice Address - Fax:470-251-5301
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC133964207L00000X
GA66346207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003118346CMedicaid
NC60125BMedicare UPIN