Healthcare Provider Details

I. General information

NPI: 1104918457
Provider Name (Legal Business Name): THOMAS J LEGG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18452 BUSINESS 13
BRANSON WEST MO
65737-9609
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-272-8911
  • Fax:
Mailing address:
  • Phone: 417-269-0269
  • Fax: 417-269-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9466
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: