Provider Demographics
NPI:1053303040
Name:LEAVITT, GARY D (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2555
Practice Address - Fax:315-452-2559
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2099212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00555440Medicaid
NY00555500Medicaid
NY02224500Medicaid
NY01813327Medicaid
G69254Medicare UPIN
NY01813327Medicaid
CC9591Medicare PIN
50019AMedicare PIN
CC7740Medicare PIN
NY02224500Medicaid
AA0672Medicare PIN