1366690398 NPI number — MARK DAVID LEVINE, M.D. PROFESSIONAL CORPORATION

Table of content: (NPI 1366690398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366690398 NPI number — MARK DAVID LEVINE, M.D. PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK DAVID LEVINE, M.D. PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366690398
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3841 N FREEWAY BLVD
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95834-1949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-576-7898
Provider Business Mailing Address Fax Number:
916-285-0338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 CHERRY LN. STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANTECA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95337-7319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-823-2246
Provider Business Practice Location Address Fax Number:
209-823-2251
Provider Enumeration Date:
09/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEVINE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-576-7898

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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