Provider Demographics
NPI:1396720918
Name:LEFTICK, MARVEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARVEN
Middle Name:
Last Name:LEFTICK
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 1:407 EAST AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-351-2280
Mailing Address - Fax:401-721-5709
Practice Address - Street 1:407 EAST AVE.
Practice Address - Street 2:SUITE 250
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-351-2280
Practice Address - Fax:401-721-5709
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10172174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7007422Medicaid
RIG57379Medicare UPIN
RI007007422Medicare ID - Type Unspecified