Basic Information
| Provider Information | |||||||||
| NPI: | 1780789891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVY | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | GUSTAVO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4780 SW 64TH AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333144400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544341705 | ||||||||
| FaxNumber: | 9544341882 | ||||||||
| Practice Location | |||||||||
| Address1: | 2004 N FLAMINGO RD | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330283500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544508500 | ||||||||
| FaxNumber: | 9544508502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS0005566 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 271136200 | 05 | FL | MEDICAID |