Basic Information
| Provider Information | |||||||||
| NPI: | 1407890031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEAVELL | ||||||||
| FirstName: | J | ||||||||
| MiddleName: | TIMOTHY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083817312 | ||||||||
| FaxNumber: | 2083817313 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E IDAHO ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083817312 | ||||||||
| FaxNumber: | 2083817313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 04/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | M7792 | ID | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
No ID Information.