Basic Information
| Provider Information | |||||||||
| NPI: | 1336133735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEQUIRE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2055 NORMANDIE DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361112732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342884624 | ||||||||
| FaxNumber: | 3342803628 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 NORMANDIE DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361112732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342884624 | ||||||||
| FaxNumber: | 3342803628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 00013481 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME89827 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 20761 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 35-07-9272-L | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0000-39011 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | H3097 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 34736 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 00013481 | AL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | ME89827 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 20761 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 35-07-9272-L | OH | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 0000-39011 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | H3097 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 34736 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 009971820 | 05 | AL | MEDICAID | 009973725 | 05 | AL | MEDICAID | 000058867 | 01 | AL | IDTF | OTHER | 009930805 | 05 | AL | MEDICAID | 009971800 | 05 | AL | MEDICAID | 000058866 | 01 | AL | IDTF | OTHER | 107037 | 05 | AL | MEDICAID | 108071 | 05 | AL | MEDICAID | 051551047 | 05 | AL | MEDICAID | 009922335 | 05 | AL | MEDICAID | 009971830 | 05 | AL | MEDICAID | 107038 | 05 | AL | MEDICAID | 108246 | 05 | AL | MEDICAID | 270021200 | 05 | FL | MEDICAID | 009928435 | 05 | AL | MEDICAID | 009972715 | 05 | AL | MEDICAID | 009951085 | 05 | AL | MEDICAID | 051504364 | 01 | AL | IDTF | OTHER |