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Individual

DR. THOMAS MACKENZIE LEAVENWORTH

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
M.D.

Contact information

Practice address
1410 N 4TH ST, CLINTON, IA 52732-2940
(563) 244-3641
Mailing address
900 STONE MILL RD, TIPTON, IA 52772-9238

Taxonomy

Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
22498
IA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
1346230539
BLUE SHIELD
IA
05
1346230539
IA
Enumeration date
10/27/2005
Last updated
08/14/2009
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