Provider Demographics
NPI:1326115684
Name:LEVY, JERRY BENNETT (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:BENNETT
Last Name:LEVY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:385 GARRISONVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554
Mailing Address - Country:US
Mailing Address - Phone:540-659-3104
Mailing Address - Fax:540-659-0892
Practice Address - Street 1:385 GARRISONVILLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554
Practice Address - Country:US
Practice Address - Phone:540-659-3104
Practice Address - Fax:540-659-0892
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
B07683Medicare UPIN