=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174834246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSH LEAVITT DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2010
-----------------------------------------------------
Last Update Date | 12/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 974 W CORPORATE LN STE 102
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-1930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-252-9404
-----------------------------------------------------
Fax | 208-391-5980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 974 W CORPORATE LN STE 102
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-1930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-252-9404
-----------------------------------------------------
Fax | 208-391-5980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | DO164436
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | O-0647
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------