Healthcare Provider Details

I. General information

NPI: 1619298411
Provider Name (Legal Business Name): JEFFREY P. LEVENDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7980 W JEFFERSON BLVD
FORT WAYNE IN
46804-4170
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-478-5210
  • Fax: 260-478-5240
Mailing address:
  • Phone: 260-479-3516
  • Fax: 260-479-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number01070886A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01070886
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: