Healthcare Provider Details

I. General information

NPI: 1053311076
Provider Name (Legal Business Name): LINDA H LEAVENWORTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 MASSACHUSETTS AVE SUITE 202
ACTON MA
01720-3739
US

IV. Provider business mailing address

411 MASSACHUSETTS AVE SUITE 202
ACTON MA
01720-3739
US

V. Phone/Fax

Practice location:
  • Phone: 978-635-0477
  • Fax:
Mailing address:
  • Phone: 978-635-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number56101
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number56101
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: