Provider Demographics
NPI:1326022484
Name:LEVINE, MELISSA DIANE (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:LEVINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2260 N ROSEMONT BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2137
Mailing Address - Country:US
Mailing Address - Phone:520-318-1033
Mailing Address - Fax:520-318-1338
Practice Address - Street 1:5055 E BROADWAY BLVD
Practice Address - Street 2:SUITE A100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3640
Practice Address - Country:US
Practice Address - Phone:520-327-0460
Practice Address - Fax:520-795-0225
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2020-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ21943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ311738Medicaid
AZZ155158OtherPTAN
AZ311738Medicaid
75729Medicare ID - Type Unspecified