Healthcare Provider Details

I. General information

NPI: 1386672343
Provider Name (Legal Business Name): KENNETH M LEAVITT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PARKER HILL AVE STE 390
BOSTON MA
02120-2847
US

IV. Provider business mailing address

67 MILLBROOK ST. C/O CHM
WORCESTER MA
01606-2835
US

V. Phone/Fax

Practice location:
  • Phone: 617-277-3800
  • Fax: 617-277-3808
Mailing address:
  • Phone: 508-795-0009
  • Fax: 508-795-0393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number1680
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1680
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: