Provider Demographics
NPI:1447585245
Name:MARK DAVID LEVINE MD, FORT BRAGG PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARK DAVID LEVINE MD, FORT BRAGG PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-785-4636
Mailing Address - Street 1:2081 ARENA BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-2309
Mailing Address - Country:US
Mailing Address - Phone:916-285-8971
Mailing Address - Fax:916-285-0338
Practice Address - Street 1:700 RIVER DR
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5403
Practice Address - Country:US
Practice Address - Phone:916-285-8977
Practice Address - Fax:916-285-0338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty