Provider Demographics
NPI:1942462486
Name:LEAVITT, ERIC JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JOHN
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9754
Practice Address - Street 1:3055 W WABASH
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6414
Practice Address - Country:US
Practice Address - Phone:217-793-2273
Practice Address - Fax:309-693-9754
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010313152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208479Medicare PIN
IL0295700011Medicare NSC