Provider Demographics
NPI:1982634648
Name:LEGOSTAEV, IGOR V (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:V
Last Name:LEGOSTAEV
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 1:344 FUNSTON PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-6819
Mailing Address - Country:US
Mailing Address - Phone:706-767-3688
Mailing Address - Fax:
Practice Address - Street 1:344 FUNSTON PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-6819
Practice Address - Country:US
Practice Address - Phone:706-767-3688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58067207R00000X
TXU0150208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00637907OtherRR MEDICARE
GAP00637907OtherRR MEDICARE
GA511I110436Medicare PIN