Provider Demographics
NPI:1053311076
Name:LEAVENWORTH, LINDA H (MD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:H
Last Name:LEAVENWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3739
Mailing Address - Country:US
Mailing Address - Phone:978-635-0477
Mailing Address - Fax:
Practice Address - Street 1:411 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3739
Practice Address - Country:US
Practice Address - Phone:978-635-0477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56101174400000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA056101OtherTUFTS HEALTH PLAN
MA2018428OtherAETNA INSURANCE
MA3023311Medicaid
MD82830OtherFALLON INSURANCE
MD13614OtherHARVARD PILGRIM HEALTH
MAJ06513OtherBLUE CROSS & BLUE SHIELD
MAJ06513OtherBLUE CROSS & BLUE SHIELD