Provider Demographics
NPI:1578610093
Name:LEAVELLE, JULIE (DPM)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:LEAVELLE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4322
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91308-4322
Mailing Address - Country:US
Mailing Address - Phone:818-455-7667
Mailing Address - Fax:
Practice Address - Street 1:418 SAN FERNANDO MISSION BLVD
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-3530
Practice Address - Country:US
Practice Address - Phone:818-455-7667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3372213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E33720Medicaid
T19316Medicare UPIN
CA000E33720Medicaid