Provider Demographics
NPI:1174834246
Name:LEAVITT, JOSH (DO)
Entity Type:Individual
Prefix:
First Name:JOSH
Middle Name:
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 W CORPORATE LN STE 102
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1930
Mailing Address - Country:US
Mailing Address - Phone:208-252-9404
Mailing Address - Fax:208-391-5980
Practice Address - Street 1:974 W CORPORATE LN STE 102
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1930
Practice Address - Country:US
Practice Address - Phone:208-252-9404
Practice Address - Fax:208-391-5980
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO164436207Q00000X
IDO-0647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine