Provider Demographics
NPI:1760678155
Name:MATTHEW O LEAVITT MD INC
Entity Type:Organization
Organization Name:MATTHEW O LEAVITT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:O
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-225-5409
Mailing Address - Street 1:PO BOX 1442
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84603-1442
Mailing Address - Country:US
Mailing Address - Phone:801-225-5407
Mailing Address - Fax:801-225-5623
Practice Address - Street 1:945 S OREM BLVD
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5011
Practice Address - Country:US
Practice Address - Phone:801-225-5407
Practice Address - Fax:801-225-5623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT65908671205207ZC0500X, 207ZD0900X, 207ZI0100X, 207ZN0500X, 207ZP0007X, 207ZP0102X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathologyGroup - Multi-Specialty
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathologyGroup - Multi-Specialty
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic PathologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063499Medicare PIN