Provider Demographics
NPI:1295841856
Name:LEAVITT, THOMAS A (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 CITY HALL MALL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4754
Mailing Address - Country:US
Mailing Address - Phone:781-306-5184
Mailing Address - Fax:781-306-5303
Practice Address - Street 1:26 CITY HALL MALL
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4754
Practice Address - Country:US
Practice Address - Phone:781-306-5184
Practice Address - Fax:781-306-5303
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW16047OtherBLUE CROSS BLUE SHIELD
MD0014551OtherNEIGHBORHOOD HEALTH
MA4317868-002OtherHEALTHSOURCE
MAE263OtherHARVARD PILGRIM
MD003638OtherTUFTS HEALTH PLAN
MA0312860Medicaid
MA4317868-002OtherCIGNA
MA4317868-002OtherCIGNA
MA0312860Medicaid