Basic Information
| Provider Information | |||||||||
| NPI: | 1144257338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVINE | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603588661 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SAYBROOK RD | ||||||||
| Address2: | SUITE N100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603441801 | ||||||||
| FaxNumber: | 8603588657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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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 | 030892 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001308924 | 05 | CT | MEDICAID |