Provider Demographics
NPI:1720181324
Name:LEAVITT, TERRY H (DPM)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:H
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 S EASTERN
Mailing Address - Street 2:#106
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119
Mailing Address - Country:US
Mailing Address - Phone:702-456-1441
Mailing Address - Fax:702-456-3901
Practice Address - Street 1:4660 S EASTERN
Practice Address - Street 2:#106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119
Practice Address - Country:US
Practice Address - Phone:702-456-1441
Practice Address - Fax:702-456-3901
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV24213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000SHBBCMedicare ID - Type Unspecified
T67272Medicare UPIN