Provider Demographics
NPI:1023032034
Name:LEVERETT, LARRY CORNELIUS (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CORNELIUS
Last Name:LEVERETT
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 1:4530 E RAY RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6094
Mailing Address - Country:US
Mailing Address - Phone:480-706-5830
Mailing Address - Fax:480-706-1800
Practice Address - Street 1:4530 E RAY RD
Practice Address - Street 2:SUITE 140
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6094
Practice Address - Country:US
Practice Address - Phone:480-706-5830
Practice Address - Fax:480-706-1800
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ119168174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ24219Medicare ID - Type UnspecifiedMEDICARE