Basic Information
| Provider Information | |||||||||
| NPI: | 1760431225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVY | ||||||||
| FirstName: | ERNESTO | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEVY | ||||||||
| OtherFirstName: | ERNESTO | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11143 PARKVIEW PLAZA DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668820 | ||||||||
| FaxNumber: | 2602668829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | MD423583 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | MD23773 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 100125 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 55071 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 83470 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 263037 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 01064370A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 1008690920001 | 05 | PA | MEDICAID |