Provider Demographics
NPI:1154484079
Name:LEVINE, MARIE R (OD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:R
Last Name:LEVINE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2167
Mailing Address - Country:US
Mailing Address - Phone:201-438-4418
Mailing Address - Fax:201-438-3082
Practice Address - Street 1:33 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2167
Practice Address - Country:US
Practice Address - Phone:201-438-4418
Practice Address - Fax:201-438-3082
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00423300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT89074Medicare UPIN
NJ580711DLSMedicare PIN