Provider Demographics
NPI:1336133735
Name:LEQUIRE, MARK H (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:LEQUIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2055 NORMANDIE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2732
Mailing Address - Country:US
Mailing Address - Phone:334-288-4624
Mailing Address - Fax:334-280-3628
Practice Address - Street 1:2055 NORMANDIE DR
Practice Address - Street 2:SUITE 108
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2732
Practice Address - Country:US
Practice Address - Phone:334-288-4624
Practice Address - Fax:334-280-3628
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000134812085R0202X, 2085R0204X
FLME898272085R0202X, 2085R0204X
SC207612085R0202X, 2085R0204X
OH35-07-9272-L2085R0202X, 2085R0204X
NC0000-390112085R0202X, 2085R0204X
TXH30972085R0202X, 2085R0204X
TN347362085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009971820Medicaid
AL009973725Medicaid
AL000058867OtherIDTF
AL009930805Medicaid
AL009971800Medicaid
AL000058866OtherIDTF
AL107037Medicaid
AL108071Medicaid
AL051551047Medicaid
AL009922335Medicaid
AL009971830Medicaid
AL107038Medicaid
AL108246Medicaid
FL270021200Medicaid
AL009928435Medicaid
AL009972715Medicaid
AL009951085Medicaid
AL051504364OtherIDTF
AL009922335Medicaid
AL107037Medicaid
AL051514818Medicare PIN
AL051504364OtherIDTF
AL107038Medicaid
AL051555300Medicare PIN