Provider Demographics
NPI:1386672343
Name:LEAVITT, KENNETH M (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:67 MILLBROOK ST.
Mailing Address - Street 2:C/O CHM
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2835
Mailing Address - Country:US
Mailing Address - Phone:508-795-0009
Mailing Address - Fax:508-795-0393
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:STE 390
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-277-3800
Practice Address - Fax:617-277-3808
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2015-03-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA1680207XX0004X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA350273Medicaid
MA6136140001Medicare NSC
MAT58743Medicare UPIN
Y70743Medicare Oscar/Certification
6136140001Medicare NSC
MA350273Medicaid