Healthcare Provider Details

I. General information

NPI: 1558354571
Provider Name (Legal Business Name): EDWARD A LEGAKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W GORE BLVD SUITE 100
LAWTON OK
73505-6378
US

IV. Provider business mailing address

3201 W GORE BLVD SUITE 100
LAWTON OK
73505-6378
US

V. Phone/Fax

Practice location:
  • Phone: 580-353-8942
  • Fax: 580-353-5008
Mailing address:
  • Phone: 580-353-8942
  • Fax: 580-353-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12378
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: