Provider Demographics
NPI:1851543557
Name:LEAVITT, TRACY KYLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:KYLE
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:68 N PECOS RD
Mailing Address - Street 2:STE A
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7339
Mailing Address - Country:US
Mailing Address - Phone:702-456-1441
Mailing Address - Fax:702-456-3901
Practice Address - Street 1:68 N PECOS RD
Practice Address - Street 2:STE A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7339
Practice Address - Country:US
Practice Address - Phone:702-456-1441
Practice Address - Fax:702-456-3901
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0701213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6453380001Medicare UPIN