Healthcare Provider Details

I. General information

NPI: 1992092894
Provider Name (Legal Business Name): JOSHUA DAHL LEAVITT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2308 96 ST NW
EDMONTON AB
T6N 1J8
CA

IV. Provider business mailing address

BOX 657 CARDSTON AB T0K0K0
CARDSTON ALBERTA
T0K0K0
CA

V. Phone/Fax

Practice location:
  • Phone: 877-444-3668
  • Fax:
Mailing address:
  • Phone: 403-653-2877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC006294
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: