Provider Demographics
NPI:1114964608
Name:LEVINE, DIANE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:LEVINE
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Gender:F
Credentials:MD
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Mailing Address - Street 1:1560 E MAPLE ROAD
Mailing Address - Street 2:SUITE 400- CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-745-4525
Mailing Address - Fax:331-396-6730
Practice Address - Street 1:50 E CANFIELD ST
Practice Address - Street 2:GENERAL MEDICINE AMBULATORY PRACTICE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1804
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-966-7305
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-02-05
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Provider Licenses
StateLicense IDTaxonomies
MI4301046192207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630154Medicare PIN