Basic Information
| Provider Information | |||||||||
| NPI: | 1790811198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVINE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 MANOR LN | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117902817 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 203 HALF HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | DIX HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316737700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 177307 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 177307 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 177307 | 05 | NY | MEDICAID |