Provider Demographics
NPI:1801879622
Name:LEVENTHAL, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:LEVENTHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9805
Mailing Address - Street 2:300 GEORGE ST, 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:YNHH BASEMENT
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-688-2468
Practice Address - Fax:203-688-7274
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT020734208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001207349Medicaid
CT001207349Medicaid
CT370000348Medicare ID - Type Unspecified