Provider Demographics
NPI:1063634434
Name:LEVIN, JACK N (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:N
Last Name:LEVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 LAVER CT # 2
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-6767
Mailing Address - Country:US
Mailing Address - Phone:650-964-6314
Mailing Address - Fax:
Practice Address - Street 1:1970 LAVER CT # 2
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-6767
Practice Address - Country:US
Practice Address - Phone:650-964-6314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32109207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC32109OtherSTATE LICENSE
CAAL5825457OtherDEA NUMBER
CAAL5825457OtherDEA NUMBER