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
StateLicense IDTaxonomies
NC2019-02503207ZH0000X, 207ZP0102X
RIDO00627207ZP0102X, 207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2019-02503OtherSTATE LICENSE