Provider Demographics
NPI:1407890031
Name:LEAVELL, J TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:TIMOTHY
Last Name:LEAVELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-7312
Mailing Address - Fax:208-381-7313
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-381-7312
Practice Address - Fax:208-381-7313
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM77922080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics