Healthcare Provider Details

I. General information

NPI: 1841414166
Provider Name (Legal Business Name): THOMAS J. LEAVITT MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 BUCK RUN
SAGLE ID
83860
US

IV. Provider business mailing address

284 BUCK RUN
SAGLE ID
83860
US

V. Phone/Fax

Practice location:
  • Phone: 208-255-7564
  • Fax: 208-255-7537
Mailing address:
  • Phone: 208-255-7564
  • Fax: 208-255-7537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberM9379
License Number StateID

VIII. Authorized Official

Name: THOMAS J LEAVITT
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 208-255-7564