Provider Demographics
NPI:1194900167
Name:LEAVENGOOD, DOUGLAS CLINTON (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CLINTON
Last Name:LEAVENGOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 PASS RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2125
Mailing Address - Country:US
Mailing Address - Phone:228-388-7743
Mailing Address - Fax:
Practice Address - Street 1:2561 PASS RD
Practice Address - Street 2:SUITE D
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2125
Practice Address - Country:US
Practice Address - Phone:228-388-7743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11243207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110476Medicaid
MS00110476Medicaid