Provider Demographics
NPI:1689774234
Name:LEAVITT, LISA ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNE
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:300 PROFESSIONAL CENTER DR
Mailing Address - Street 2:SUITE 311
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4334
Mailing Address - Country:US
Mailing Address - Phone:415-448-1555
Mailing Address - Fax:415-892-8732
Practice Address - Street 1:250 BON AIR RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-448-1500
Practice Address - Fax:415-461-4229
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG080605208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
BL4460820OtherDEA
G21706Medicare UPIN