Provider Demographics
NPI:1376681445
Name:LEVY, RICHARD FREDERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:FREDERIC
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 1:1811 WILSHIRE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5626
Mailing Address - Country:US
Mailing Address - Phone:310-453-9010
Mailing Address - Fax:
Practice Address - Street 1:934 21ST ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-3433
Practice Address - Country:US
Practice Address - Phone:310-383-3297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24539208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G245390Medicaid
CA00G245390Medicaid