Provider Demographics
NPI:1659331296
Name:LEGARDA, MARIS STELLA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIS
Middle Name:STELLA
Last Name:LEGARDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WILSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-7885
Mailing Address - Country:US
Mailing Address - Phone:831-242-8645
Mailing Address - Fax:
Practice Address - Street 1:23845 HOLMAN HWY STE 210
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5907
Practice Address - Country:US
Practice Address - Phone:831-620-0700
Practice Address - Fax:831-620-0304
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC528342084N0402X, 2084E0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6906099Medicaid
SC96243OtherMEDCOST
SCT30936Medicaid
SC5004685OtherAETNA
SC5004685OtherAETNA
SCF39818Medicare PIN
DC1754084YT2Medicare PIN