Provider Demographics
NPI:1588807218
Name:KENT G LEAVITT MD PLLC
Entity Type:Organization
Organization Name:KENT G LEAVITT MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-450-6990
Mailing Address - Street 1:1135 116TH AVE NE STE 450
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4623
Mailing Address - Country:US
Mailing Address - Phone:425-450-6990
Mailing Address - Fax:425-450-8807
Practice Address - Street 1:14841 179TH AVE SE STE 110
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1127
Practice Address - Country:US
Practice Address - Phone:425-450-6990
Practice Address - Fax:425-450-8807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0028489207W00000X
207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2008218Medicaid
WAG8868816Medicare PIN
WA180041068Medicare PIN
WA2008218Medicaid