Provider Demographics
NPI:1386698678
Name:LEAVITT, PETER S (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:LEAVITT
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-657-4400
Mailing Address - Fax:
Practice Address - Street 1:1473 S HIGHWAY 40 STE E
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3522
Practice Address - Country:US
Practice Address - Phone:435-657-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10696960-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500640858Medicaid
ME417210099Medicaid
OR500640858Medicaid
ORR162152Medicare PIN
MEME0763Medicare PIN
ME417210099Medicaid