Healthcare Provider Details

I. General information

NPI: 1851370332
Provider Name (Legal Business Name): BENJAMIN LEGGIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 JEFFERSON STREET
MANSFIELD LA
71052
US

IV. Provider business mailing address

207 JEFFERSON ST
MANSFIELD LA
71052-2603
US

V. Phone/Fax

Practice location:
  • Phone: 318-872-2700
  • Fax: 318-872-6214
Mailing address:
  • Phone: 318-872-2700
  • Fax: 318-872-6214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD019092
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: