Provider Demographics
NPI:1356493431
Name:LEVERETT, DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:LEVERETT
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 1:2205 PINTAIL DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-7360
Mailing Address - Country:US
Mailing Address - Phone:303-521-6773
Mailing Address - Fax:
Practice Address - Street 1:1260 S HOVER ST
Practice Address - Street 2:SUITE E
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-7911
Practice Address - Country:US
Practice Address - Phone:303-684-3619
Practice Address - Fax:303-774-3082
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT 1892152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU98893Medicare UPIN
COC524698Medicare ID - Type Unspecified