Provider Demographics
NPI:1477075836
Name:LEVINE, MATTHEW JORDAN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JORDAN
Last Name:LEVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 REDWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1654
Mailing Address - Country:US
Mailing Address - Phone:917-612-2615
Mailing Address - Fax:
Practice Address - Street 1:15 REDWOOD LOOP
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309
Practice Address - Country:US
Practice Address - Phone:917-612-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist