Provider Demographics
NPI:1760498646
Name:LEVETT, LAURENCE MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:MARTIN
Last Name:LEVETT
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 1:3851 ROGER BROOKE DRIVE
Mailing Address - Street 2:ATTN TRAILER 15/IMC
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4501
Mailing Address - Country:US
Mailing Address - Phone:210-916-1415
Mailing Address - Fax:
Practice Address - Street 1:600 N UNION AVE
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-4194
Practice Address - Country:US
Practice Address - Phone:830-643-6252
Practice Address - Fax:830-643-6255
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3303207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164788503Medicaid
TX164788502Medicaid
TX0069NKOtherBC/BS ID
TX8W2431OtherBC/BS
TX164788503Medicaid
TX164788502Medicaid
P00287035Medicare PIN
612214Medicare PIN