Basic Information
| Provider Information | |||||||||
| NPI: | 1326022484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVINE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2260 N ROSEMONT BLVD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203181033 | ||||||||
| FaxNumber: | 5203181338 | ||||||||
| Practice Location | |||||||||
| Address1: | 5055 E BROADWAY BLVD | ||||||||
| Address2: | SUITE A100 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857113640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203270460 | ||||||||
| FaxNumber: | 5207950225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21943 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 311738 | 05 | AZ | MEDICAID | Z155158 | 01 | AZ | PTAN | OTHER |