Provider Demographics
NPI: | 1619194560 |
---|---|
Name: | LEGOLVAN, MARK P (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARK |
Middle Name: | P |
Last Name: | LEGOLVAN |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 30369 |
Mailing Address - Street 2: | |
Mailing Address - City: | WINSTON SALEM |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27130-0369 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 336-306-5777 |
Mailing Address - Fax: | 336-999-8889 |
Practice Address - Street 1: | 105 W 4TH ST STE 600 |
Practice Address - Street 2: | |
Practice Address - City: | WINSTON SALEM |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27101-3816 |
Practice Address - Country: | US |
Practice Address - Phone: | 336-306-5777 |
Practice Address - Fax: | 401-444-5088 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-04-20 |
Last Update Date: | 2022-10-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 2019-02503 | 207ZH0000X, 207ZP0102X |
RI | DO00627 | 207ZP0102X, 207ZH0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207ZH0000X | Allopathic & Osteopathic Physicians | Pathology | Hematology |
No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 2019-02503 | Other | STATE LICENSE |