Provider Demographics
NPI:1982630695
Name:LEAVITT, RODNEY DERRICK (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:DERRICK
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 1:1226 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1424
Mailing Address - Country:US
Mailing Address - Phone:541-476-6636
Mailing Address - Fax:541-476-6690
Practice Address - Street 1:1226 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1424
Practice Address - Country:US
Practice Address - Phone:541-476-6636
Practice Address - Fax:541-476-6690
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26491207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD26491OtherOREGON BOARD OF MED EXAM