Basic Information
| Provider Information | |||||||||
| NPI: | 1871593285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVENGOOD | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 RIVERSIDE PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300435925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702373475 | ||||||||
| FaxNumber: | 7702373756 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 RIVERSIDE PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300435925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702373475 | ||||||||
| FaxNumber: | 7702373756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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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 | 207X00000X | 040138 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 040138 | GA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200045077 | 01 | GA | RAILROAD MEDICARE | OTHER | 000665409F | 05 | GA | MEDICAID |