Provider Demographics
NPI:1144409137
Name:LEVIN, JONATHAN JAY (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAY
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 1:18325 N ALLIED WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-3105
Mailing Address - Country:US
Mailing Address - Phone:602-467-4966
Mailing Address - Fax:480-419-5401
Practice Address - Street 1:18325 N ALLIED WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-3105
Practice Address - Country:US
Practice Address - Phone:602-467-4966
Practice Address - Fax:480-419-5401
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51173207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
IAENROLLEDMedicaid