Basic Information
Provider Information | |||||||||
NPI: | 1437357951 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEVINE | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3835 N FREEWAY BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958341928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9165767898 | ||||||||
FaxNumber: | 9162850338 | ||||||||
Practice Location | |||||||||
Address1: | 3835 N FREEWAY BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958341928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9165767898 | ||||||||
FaxNumber: | 9162850338 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2007 | ||||||||
LastUpdateDate: | 05/08/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | G34333 | CA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.