Provider Demographics
NPI:1629157359
Name:LEAVITT, BENJAMIN GLEN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:GLEN
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 1:600 W CALE ST
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-2423
Mailing Address - Country:US
Mailing Address - Phone:417-236-9295
Mailing Address - Fax:
Practice Address - Street 1:203 S WASHINGTON AVE STE A
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-1466
Practice Address - Country:US
Practice Address - Phone:417-678-4022
Practice Address - Fax:417-678-4025
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2004016417OtherMEDICAL LICENCE NUMBER
MO8070773OtherAAFP I.D. NUMBER
MO8070773OtherAAFP I.D. NUMBER
MO8070773OtherAAFP I.D. NUMBER