Provider Demographics
NPI:1174505739
Name:LEAVITT, RICHARD J (D,O)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:D,O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 OLD YORK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-3707
Mailing Address - Country:US
Mailing Address - Phone:215-885-6767
Mailing Address - Fax:215-885-5297
Practice Address - Street 1:201 OLD YORK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3707
Practice Address - Country:US
Practice Address - Phone:215-885-6767
Practice Address - Fax:215-885-5297
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2015-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004493L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000908296Medicaid
PA000908296Medicaid
PA184789FTMMedicare ID - Type Unspecified