1053303040 NPI number — DR. GARY D LEAVITT M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053303040 NPI number — DR. GARY D LEAVITT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAVITT
Provider First Name:
GARY
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053303040
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4567 CROSSROADS PARK DR
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
LIVERPOOL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13088-3589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-295-2100
Provider Business Mailing Address Fax Number:
315-295-2125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5100 W TAFT RD
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
LIVERPOOL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13088-3807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-452-2555
Provider Business Practice Location Address Fax Number:
315-452-2559
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  209921 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00555440 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00555500 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02224500 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01813327 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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