Provider Demographics
NPI:1528042959
Name:LEAVITT, COLLEEN MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:MARY
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9910 FRANKLIN SQUARE DR # 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:
Practice Address - Street 1:1000 E EAGER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202
Practice Address - Country:US
Practice Address - Phone:410-522-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD945LS695Medicare PIN
MD342939YWV2Medicare PIN
MD149831ZDDBMedicare PIN