1205910304 NPI number — CRAIG MITCHELL LEAVITT D.C.

Table of content: CRAIG MITCHELL LEAVITT D.C. (NPI 1205910304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205910304 NPI number — CRAIG MITCHELL LEAVITT D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAVITT
Provider First Name:
CRAIG
Provider Middle Name:
MITCHELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1205910304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 WHITE RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
LITTLE SILVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07739-1166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-530-1525
Provider Business Mailing Address Fax Number:
732-530-1527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 WHITE RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
LITTLE SILVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07739-1166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-530-1525
Provider Business Practice Location Address Fax Number:
732-530-1527
Provider Enumeration Date:
10/25/2006

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: 111N00000X , with the licence number:  MC04814 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2644883 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5851224 . This is a "AETNA TRADITIONAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: P1974471 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".




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