Provider Demographics
NPI:1457609653
Name:LEGACY MEDICAL PLLC
Entity type:Organization
Organization Name:LEGACY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MADHU
Authorized Official - Middle Name:
Authorized Official - Last Name:BOPPANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:646-270-1050
Mailing Address - Street 1:245 8TH AVE # 101
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1607
Mailing Address - Country:US
Mailing Address - Phone:646-270-1050
Mailing Address - Fax:
Practice Address - Street 1:3741 77TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6629
Practice Address - Country:US
Practice Address - Phone:718-406-9588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199052-12084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty