Healthcare Provider Details

I. General information

NPI: 1386644318
Provider Name (Legal Business Name): GLENN RALPH LEAVITT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 ELK CRK
IDAHO FALLS ID
83404-8322
US

IV. Provider business mailing address

1550 ELK CRK
IDAHO FALLS ID
83404-8322
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-5942
  • Fax: 208-529-5951
Mailing address:
  • Phone: 208-535-4580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberO-0365
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: