Healthcare Provider Details

I. General information

NPI: 1336133735
Provider Name (Legal Business Name): MARK H LEQUIRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 NORMANDIE DR SUITE 108
MONTGOMERY AL
36111-2732
US

IV. Provider business mailing address

2055 NORMANDIE DR SUITE 108
MONTGOMERY AL
36111-2732
US

V. Phone/Fax

Practice location:
  • Phone: 334-288-4624
  • Fax: 334-280-3628
Mailing address:
  • Phone: 334-288-4624
  • Fax: 334-280-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number00013481
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME89827
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number20761
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35-07-9272-L
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0000-39011
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberH3097
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34736
License Number StateTN
# 8
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number00013481
License Number StateAL
# 9
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME89827
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number20761
License Number StateSC
# 11
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35-07-9272-L
License Number StateOH
# 12
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number0000-39011
License Number StateNC
# 13
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberH3097
License Number StateTX
# 14
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number34736
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: