Provider Demographics
NPI:1477626141
Name:LEGIDO, AGUSTIN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:AGUSTIN
Middle Name:
Last Name:LEGIDO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9003 BUTTONWOOD PL
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1056
Mailing Address - Country:US
Mailing Address - Phone:215-482-8307
Mailing Address - Fax:
Practice Address - Street 1:ERIE AENUE
Practice Address - Street 2:FRONT STREET
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134
Practice Address - Country:US
Practice Address - Phone:215-427-5452
Practice Address - Fax:215-427-4393
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040350L2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012056390008Medicaid
PAE71367Medicare UPIN
PA0012056390008Medicaid