Provider Demographics
NPI:1346230539
Name:LEAVENWORTH, THOMAS MACKENZIE (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MACKENZIE
Last Name:LEAVENWORTH
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 1:900 STONE MILL RD
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IA
Mailing Address - Zip Code:52772-9238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 N 4TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2940
Practice Address - Country:US
Practice Address - Phone:563-244-3641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22498207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1346230539OtherBLUE SHIELD
IA1346230539Medicaid
IA1346230539OtherBLUE SHIELD