Healthcare Provider Details

I. General information

NPI: 1528062320
Provider Name (Legal Business Name): KENT G LEAVITT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE STE 450
BELLEVUE WA
98004-4623
US

IV. Provider business mailing address

2285 116TH AVE NE
BELLEVUE WA
98004-3015
US

V. Phone/Fax

Practice location:
  • Phone: 425-450-6990
  • Fax: 425-450-8807
Mailing address:
  • Phone: 425-426-2880
  • Fax: 425-450-9696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License NumberMD00028489
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD00028489
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: