Provider Demographics
NPI:1003340175
Name:LEAVITT, ALIDA OVRUTSKY (MD)
Entity Type:Individual
Prefix:DR
First Name:ALIDA
Middle Name:OVRUTSKY
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ALIDA
Other - Middle Name:ROSE
Other - Last Name:OVRUTSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY STE 900
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2476
Practice Address - Country:US
Practice Address - Phone:207-874-2445
Practice Address - Fax:207-523-8598
Is Sole Proprietor?:No
Enumeration Date:2017-04-16
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0006651390200000X
MEMD24923207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program