Provider Demographics
NPI:1164564662
Name:LEVINE, SUSAN M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:LEVINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:LEVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:115 E 72ND ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4262
Mailing Address - Country:US
Mailing Address - Phone:212-472-4816
Mailing Address - Fax:212-472-9660
Practice Address - Street 1:115 E 72ND ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4262
Practice Address - Country:US
Practice Address - Phone:212-472-4816
Practice Address - Fax:212-472-9660
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150459-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02F101Medicare ID - Type Unspecified