Provider Demographics
NPI:1225095839
Name:LEVIN, LEE A (OD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:A
Last Name:LEVIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:LEE
Other - Middle Name:A
Other - Last Name:LEVIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3733 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-1501
Mailing Address - Country:US
Mailing Address - Phone:219-887-0030
Mailing Address - Fax:
Practice Address - Street 1:3733 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1501
Practice Address - Country:US
Practice Address - Phone:219-887-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001648B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100167250Medicaid
IN495030Medicare ID - Type Unspecified
IN100167250Medicaid