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NPI Code Detail

MEDICARE: MARK P LEGOLVAN D.O.

MEDICARE: MARK P LEGOLVAN D.O.
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
1207ZH0000XHematology (Pathology) Physician2019-02503NC
2207ZP0102XAnatomic Pathology & Clinical Pathology PhysicianDO00627RI
3207ZP0102XAnatomic Pathology & Clinical Pathology Physician2019-02503NC
4207ZH0000XHematology (Pathology) PhysicianDO00627RI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12019-02503OTHERNCSTATE LICENSE

General Provider Information

NPI Number : 1619194560
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK P LEGOLVAN D.O.
Provider Business Mailing Address
First Line : PO BOX 30369
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27130-0369
Country : US
Telephone Number : 336-306-5777
Fax Number : 336-999-8889
Provider Business Practice Location Address
First Line : 706 GREEN VALLEY RD STE 104
Second Line :
City : GREENSBORO
State : NC
Zip : 27408-7043
Country : US
Telephone Number : 336-387-2500
Fax Number : 336-387-2501
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/20/2007
Last Update Date : 10/15/2025

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