Provider Demographics
NPI:1528189115
Name:LEVY, PHILLIP (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:LEVY
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 1:5020 BALTIMORE DR STE B
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-0692
Mailing Address - Country:US
Mailing Address - Phone:619-464-8303
Mailing Address - Fax:
Practice Address - Street 1:5020 BALTIMORE DR STE B
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3692
Practice Address - Country:US
Practice Address - Phone:619-464-8303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA04884T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0048840Medicaid
CAT69963Medicare UPIN
CASD0048840Medicaid