Provider Demographics
NPI:1528075744
Name:LEAVITT, THOMAS J (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
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 1:284 BUCK RUN
Mailing Address - Street 2:
Mailing Address - City:SAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83860
Mailing Address - Country:US
Mailing Address - Phone:208-255-7564
Mailing Address - Fax:208-255-7537
Practice Address - Street 1:284 BUCK RUN
Practice Address - Street 2:
Practice Address - City:SAGLE
Practice Address - State:ID
Practice Address - Zip Code:83860
Practice Address - Country:US
Practice Address - Phone:208-255-7564
Practice Address - Fax:208-255-7537
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9379207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A38180Medicare UPIN
ID1131171Medicare PIN