Provider Demographics
NPI:1639448350
Name:LEAVITT, WAYNE L
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:L
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S STEMMONS FWY STE F
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-4563
Mailing Address - Country:US
Mailing Address - Phone:214-668-1256
Mailing Address - Fax:972-221-0099
Practice Address - Street 1:211 S STEMMONS FWY STE F
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4563
Practice Address - Country:US
Practice Address - Phone:214-668-1256
Practice Address - Fax:972-221-0099
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01-69252-01247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX01-6925201Medicaid