1386672343 NPI number — KENNETH M LEAVITT DPM

Table of content: KENNETH M LEAVITT DPM (NPI 1386672343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386672343 NPI number — KENNETH M LEAVITT DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAVITT
Provider First Name:
KENNETH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1386672343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 MILLBROOK ST.
Provider Second Line Business Mailing Address:
C/O CHM
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01606-2835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-795-0009
Provider Business Mailing Address Fax Number:
508-795-0393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 PARKER HILL AVE
Provider Second Line Business Practice Location Address:
STE 390
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02120-2847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-277-3800
Provider Business Practice Location Address Fax Number:
617-277-3808
Provider Enumeration Date:
06/29/2006

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: 207XX0004X , with the licence number:  1680 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 1680 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350273 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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