Provider Demographics
NPI:1962948935
Name:LEGGETT, PORCHA (MD)
Entity type:Individual
Prefix:DR
First Name:PORCHA
Middle Name:
Last Name:LEGGETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:765-472-5335
Mailing Address - Fax:
Practice Address - Street 1:285 W 12TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1653
Practice Address - Country:US
Practice Address - Phone:765-472-5335
Practice Address - Fax:260-479-2921
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01083381A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300040942Medicaid