Provider Demographics
NPI:1427033224
Name:LEGENZA, MARY TERESA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:LEGENZA
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 1:1400 HAL GREER BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4114
Mailing Address - Country:US
Mailing Address - Phone:304-399-6556
Mailing Address - Fax:304-399-6554
Practice Address - Street 1:1400 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-4114
Practice Address - Country:US
Practice Address - Phone:304-399-6556
Practice Address - Fax:304-399-6554
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25804208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64271133Medicaid
KY000000213230OtherBLUE SHIELD
KY0694003Medicare ID - Type Unspecified
KY64271133Medicaid
KYK018270Medicare PIN