Provider Demographics
NPI:1326332123
Name:LEVIN, ETHAN C (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:C
Last Name:LEVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3255
Mailing Address - Country:US
Mailing Address - Phone:512-759-8932
Mailing Address - Fax:
Practice Address - Street 1:5600 EUBANK BLVD NE STE 110
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1519
Practice Address - Country:US
Practice Address - Phone:314-996-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122015207ND0101X
NMMD2019-0595207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery