Provider Demographics
NPI:1104918457
Name:LEGG, THOMAS J (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:LEGG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-0269
Mailing Address - Fax:417-269-0279
Practice Address - Street 1:18452 BUSINESS 13
Practice Address - Street 2:
Practice Address - City:BRANSON WEST
Practice Address - State:MO
Practice Address - Zip Code:65737-9609
Practice Address - Country:US
Practice Address - Phone:417-272-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241147040Medicaid
25107OtherBLUE CROSS MO
080126695Medicare PIN
915894147Medicare PIN
25107OtherBLUE CROSS MO
A12824Medicare UPIN
915895126Medicare PIN