Provider Demographics
NPI:1558312421
Name:LEGG-JACK, TAMUNOSISI E (MD)
Entity Type:Individual
Prefix:
First Name:TAMUNOSISI
Middle Name:E
Last Name:LEGG-JACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6309 WINFIELD DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-1718
Mailing Address - Country:US
Mailing Address - Phone:405-603-4670
Mailing Address - Fax:
Practice Address - Street 1:3500 E FRANK PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2411
Practice Address - Country:US
Practice Address - Phone:918-333-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23135207PE0004X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI40642Medicare UPIN