Basic Information
| Provider Information | |||||||||
| NPI: | 1710960307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEAVY | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958256504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162868700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958256504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162868700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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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 | 207Q00000X | A070315 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A703150 | 05 | CA | MEDICAID |