Provider Demographics
NPI:1114984408
Name:LEVY, MARK J (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:LEVY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:24401 CALLE DE LA LOUISA
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3623
Mailing Address - Country:US
Mailing Address - Phone:949-951-2020
Mailing Address - Fax:949-356-1687
Practice Address - Street 1:24401 CALLE DE LA LOUISA
Practice Address - Street 2:SUITE 300
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3623
Practice Address - Country:US
Practice Address - Phone:949-951-2020
Practice Address - Fax:949-356-1687
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6989TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU93607Medicare UPIN
FV346YMedicare PIN
CAOP6989AMedicare PIN
FV346ZMedicare PIN