Basic Information
Provider Information | |||||||||
NPI: | 1366690398 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARK DAVID LEVINE, M.D. PROFESSIONAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY PSYCHIATRY ASSOCIATES, INC. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3841 N FREEWAY BLVD | ||||||||
Address2: | SUITE 120 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958341949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9165767898 | ||||||||
FaxNumber: | 9162850338 | ||||||||
Practice Location | |||||||||
Address1: | 302 CHERRY LN. STE 208 | ||||||||
Address2: |   | ||||||||
City: | MANTECA | ||||||||
State: | CA | ||||||||
PostalCode: | 953377319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2098232246 | ||||||||
FaxNumber: | 2098232251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2008 | ||||||||
LastUpdateDate: | 08/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEVINE | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | DAVID | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9165767898 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.