Provider Demographics
NPI:1437379583
Name:LEVINE, BRUCE D (DPM)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:LEVINE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 W 6TH ST
Mailing Address - Street 2:150W
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-548-1191
Mailing Address - Fax:310-548-4007
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:150W
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-548-1191
Practice Address - Fax:310-548-4007
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3485213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E34850Medicaid
CAE3485Medicare ID - Type UnspecifiedMEDICARE
CA000E34850Medicaid