Provider Demographics
NPI:1356305668
Name:LEVY, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:LEVY
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 1:2312 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2306
Mailing Address - Country:US
Mailing Address - Phone:518-274-3390
Mailing Address - Fax:518-274-3398
Practice Address - Street 1:2312 15TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2306
Practice Address - Country:US
Practice Address - Phone:518-274-3390
Practice Address - Fax:518-274-3398
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091450-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00514847Medicaid
NY00514847Medicaid
NYD72326Medicare UPIN