Provider Demographics
NPI:1467491282
Name:LEVINE, DARRYL I (OD)
Entity Type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:I
Last Name:LEVINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 COTTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1122
Mailing Address - Country:US
Mailing Address - Phone:215-745-1444
Mailing Address - Fax:215-745-1448
Practice Address - Street 1:2139 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1122
Practice Address - Country:US
Practice Address - Phone:215-745-1444
Practice Address - Fax:215-745-1448
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000266152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00640312Medicaid
PA2193348000OtherINDEPENDENCE BLUE CROSS
PA2193348000OtherKEYSTONE HEALTH PLAN EAST
PAT28373Medicare UPIN
PA087601Medicare ID - Type Unspecified