Basic Information
| Provider Information | |||||||||
| NPI: | 1639191737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEGMANN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 260023 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631268023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148493535 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15107 VANOWEN STREET | ||||||||
| Address2: | PATHOLOGY DEPARTMENT | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189022961 | ||||||||
| FaxNumber: | 8189023903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | A94915 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00A949150 | 05 | CA | MEDICAID |