Provider Demographics
NPI:1386644318
Name:LEAVITT, GLENN RALPH (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:RALPH
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 1:1550 ELK CRK
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8322
Mailing Address - Country:US
Mailing Address - Phone:208-535-4580
Mailing Address - Fax:
Practice Address - Street 1:1550 ELK CRK
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8322
Practice Address - Country:US
Practice Address - Phone:208-529-5942
Practice Address - Fax:208-529-5951
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0365207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology