Healthcare Provider Details

I. General information

NPI: 1477501203
Provider Name (Legal Business Name): LYNN LUCILLE LEVENTIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 PIONEER LN STE B
BISHOP CA
93514-2517
US

IV. Provider business mailing address

153 PIONEER LN SUITE C
BISHOP CA
93514-2517
US

V. Phone/Fax

Practice location:
  • Phone: 760-873-2602
  • Fax: 760-873-2750
Mailing address:
  • Phone: 760-873-2602
  • Fax: 760-873-2750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD0000026240
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: