Provider Demographics
NPI:1528062320
Name:LEAVITT, KENT G (MD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:G
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 1:2285 116TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3015
Mailing Address - Country:US
Mailing Address - Phone:425-426-2880
Mailing Address - Fax:425-450-9696
Practice Address - Street 1:1135 116TH AVE NE STE 450
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4623
Practice Address - Country:US
Practice Address - Phone:425-450-6990
Practice Address - Fax:425-450-8807
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028489207WX0120X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8869061Medicare PIN
WAG8868818Medicare PIN
WAE52779Medicare UPIN
WADN0066Medicare PIN
WAE52779Medicare UPIN