Healthcare Provider Details

I. General information

NPI: 1780650077
Provider Name (Legal Business Name): KIMBERLY I LEVERSEDGE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 OBERLIN RD STE A
RALEIGH NC
27608-2052
US

IV. Provider business mailing address

1321 OBERLIN ROAD SUITE A
RALEIGH NC
27608-2052
US

V. Phone/Fax

Practice location:
  • Phone: 919-828-4747
  • Fax: 919-828-6765
Mailing address:
  • Phone: 919-828-4747
  • Fax: 919-828-6765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014-00337
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: