Basic Information
| Provider Information | |||||||||
| NPI: | 1619194560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEGOLVAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30369 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271300369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363065777 | ||||||||
| FaxNumber: | 3369998889 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W 4TH ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271013816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363065777 | ||||||||
| FaxNumber: | 4014445088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZH0000X | 2019-02503 | NC | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | DO00627 | RI | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 2019-02503 | NC | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZH0000X | DO00627 | RI | Y | Allopathic & Osteopathic Physicians | Pathology | Hematology |
ID Information
| ID | Type | State | Issuer | Description | 2019-02503 | 01 | NC | STATE LICENSE | OTHER |