Provider Demographics
NPI:1578615522
Name:LEAVITT, PAUL J (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 NEW SHACKLE ISLAND RD STE 140C
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2366
Mailing Address - Country:US
Mailing Address - Phone:615-826-5664
Mailing Address - Fax:615-826-5665
Practice Address - Street 1:353 NEW SHACKLE ISLAND RD STE 140C
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2366
Practice Address - Country:US
Practice Address - Phone:615-826-5664
Practice Address - Fax:615-826-5665
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000038410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33375831Medicare PIN
TNI13850Medicare UPIN