Provider Demographics
NPI:1790778819
Name:LEGROW, REGINALD BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:BRUCE
Last Name:LEGROW
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 1:404 N KAUFMAN ST
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:TX
Mailing Address - Zip Code:75563-5234
Mailing Address - Country:US
Mailing Address - Phone:903-756-5581
Mailing Address - Fax:903-756-5005
Practice Address - Street 1:402 N KAUFMAN ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:TX
Practice Address - Zip Code:75563-5234
Practice Address - Country:US
Practice Address - Phone:903-756-5581
Practice Address - Fax:903-756-5005
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1944208000000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130943702Medicaid
834818Medicare ID - Type Unspecified
C18292Medicare UPIN