Provider Demographics
NPI:1649204892
Name:LEGAULT, DANIEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOHN
Last Name:LEGAULT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:330 E BELTLINE AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1267
Mailing Address - Country:US
Mailing Address - Phone:616-752-6235
Mailing Address - Fax:616-752-6324
Practice Address - Street 1:330 E BELTLINE AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1267
Practice Address - Country:US
Practice Address - Phone:616-752-6235
Practice Address - Fax:616-752-6324
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIDL056685207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3410503Medicaid
MIF28258Medicare UPIN
MI3410503Medicaid