Provider Demographics
NPI:1780976480
Name:LEAVITT, VAN STEPHEN (DO)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:STEPHEN
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:3477 S MERCY RD STE 208
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0448
Practice Address - Country:US
Practice Address - Phone:480-728-6590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006665208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ024924Medicaid