Provider Demographics
NPI:1922019900
Name:LEAVITT, DOUGLAS LAMONT (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LAMONT
Last Name:LEAVITT
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 1:1531 ESPLANADE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3310
Mailing Address - Country:US
Mailing Address - Phone:530-332-6300
Mailing Address - Fax:530-893-6936
Practice Address - Street 1:1531 ESPLANADE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3310
Practice Address - Country:US
Practice Address - Phone:530-332-6337
Practice Address - Fax:530-893-6936
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46018207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00314414OtherMEDICARE RAILROAD
CA00A460180Medicaid
CAP00314414OtherMEDICARE RAILROAD
CAE35879Medicare UPIN