Basic Information
Provider Information | |||||||||
NPI: | 1639448350 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEAVITT | ||||||||
FirstName: | WAYNE | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 211 S STEMMONS FWY STE F | ||||||||
Address2: |   | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750674563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146681256 | ||||||||
FaxNumber: | 9722210099 | ||||||||
Practice Location | |||||||||
Address1: | 211 S STEMMONS FWY STE F | ||||||||
Address2: |   | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750674563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146681256 | ||||||||
FaxNumber: | 9722210099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2011 | ||||||||
LastUpdateDate: | 04/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | 01-69252-01 | TX | Y |   | Technologists, Technicians & Other Technical Service Providers | Technician, Other |   |
ID Information
ID | Type | State | Issuer | Description | 01-6925201 | 05 | TX |   | MEDICAID |