MEDICARE: DR. GARY LAURENT LEGAULT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	Q1851	TX
2	207W00000X	Ophthalmology Physician	2013-00434	NC
3	208D00000X	General Practice Physician	25760	NE

General Provider Information

NPI Number	:	1538396692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY LAURENT LEGAULT M.D.

Provider Business Mailing Address
First Line	:	3551 ROGER BROOKE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78234-4504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3551 ROGER BROOKE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78234-4504
Country	:	US
Telephone Number	:	210-539-9582
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	06/22/2026

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