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General NPI Number Information
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NPI Number | 1841414166
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Entity Type | Organization
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Legal Business Name | THOMAS J. LEAVITT MD PC
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 12/04/2007
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Provider Practice Location Address
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Address Line | 284 BUCK RUN
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City | SAGLE
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State | ID
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Zip | 83860
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Country | US
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Telephone | 208-255-7564
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Fax | 208-255-7537
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Provider Business Mailing Address
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Address Line | 284 BUCK RUN
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City | SAGLE
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State | ID
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Zip | 83860
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Country | US
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Telephone | 208-255-7564
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Fax | 208-255-7537
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | THOMAS J LEAVITT
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Credential | MD
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Telephone | 208-255-7564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | M9379
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License Number State | ID
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