Provider Demographics
NPI:1588685671
Name:LEVENSON, DMITRY (MD)
Entity Type:Individual
Prefix:
First Name:DMITRY
Middle Name:
Last Name:LEVENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:
Practice Address - Street 1:344 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:MA
Practice Address - Zip Code:01570-1509
Practice Address - Country:US
Practice Address - Phone:508-671-4050
Practice Address - Fax:508-949-6742
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA47159OtherHNE
GA11SCCSXOtherMEDICARE
MA1588685671OtherCIGNA HEALTH CARE
MAAA157019OtherHPHC
MA042472266OtherTHREE RIVERS
MA1588685671OtherFCHP
GA544466114AMedicaid
MA042472266OtherFIRST HEALTH
MA042472266OtherUNITED HEALTHCARE
MA042472266OtherMULTIPLAN/PHCS
MA1588685671OtherTUFTS HEALTH PLAN
MA1588685671OtherBLUE CROSS BLUE SHIELD OF MA
MA1588685671OtherTRICARE/CHAMPUS
GA11SCCSXOtherMEDICARE