Provider Demographics
NPI:1114910460
Name:LEAVENS, THOMAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:LEAVENS
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 1:221 W. COLORADO BLVD. PAVILLION 2
Mailing Address - Street 2:SUITE 537
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208
Mailing Address - Country:US
Mailing Address - Phone:214-943-4599
Mailing Address - Fax:214-942-3549
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:#408
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-921-4191
Practice Address - Fax:817-924-3096
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ33352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPO84930F9Medicaid
TXPO84930F9Medicaid
TX84930FMedicare ID - Type Unspecified