Provider Demographics
NPI:1013430016
Name:BROWN, IVAN LEAVITT
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:LEAVITT
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 CHARTER OAK DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2934
Mailing Address - Country:US
Mailing Address - Phone:847-254-3904
Mailing Address - Fax:
Practice Address - Street 1:159 TROUT AVENUE
Practice Address - Street 2:SUBASE NEW LONDON
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:847-254-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman