Basic Information
| Provider Information | |||||||||
| NPI: | 1659304590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVENSON | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | ETHAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6654 KENTWOOD BLUFFS DR | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900451259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102164476 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2125 ARIZONA AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904041337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108298701 | ||||||||
| FaxNumber: | 3103154062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | A22502 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | P00178725 | 01 | CA | RAILROAD MEDICARE | OTHER | 00A225020 | 05 | CA | MEDICAID |