Provider Demographics
NPI:1063478196
Name:LEVINE, BRUCE J (DPM)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:LEVINE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 COUNTRYSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-1605
Mailing Address - Country:US
Mailing Address - Phone:727-797-5008
Mailing Address - Fax:797-791-1330
Practice Address - Street 1:2521 COUNTRYSIDE BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-1605
Practice Address - Country:US
Practice Address - Phone:727-797-5008
Practice Address - Fax:797-791-1330
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1802213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029701100Medicaid
FL480011623OtherRAILROAD MEDICARE
FL33537Medicare PIN
FL480011623OtherRAILROAD MEDICARE
FL0477670001Medicare NSC