MEDICARE: DR. THOMAS A. LEAVENS M.D.

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
1	2084N0400X	Neurology Physician	J3335	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114910460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS A. LEAVENS M.D.

Provider Business Mailing Address
First Line	:	221 W. COLORADO BLVD. PAVILLION 2
Second Line	:	SUITE 537
City	:	DALLAS
State	:	TX
Zip	:	75208
Country	:	US
Telephone Number	:	214-943-4599
Fax Number	:	214-942-3549

Provider Business Practice Location Address
First Line	:	1307 8TH AVE
Second Line	:	#408
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4137
Country	:	US
Telephone Number	:	817-921-4191
Fax Number	:	817-924-3096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	05/07/2014

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