Provider Demographics
NPI:1629045455
Name:LEVITSKY, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:LEVITSKY
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 1:28-04 BROADWAY
Mailing Address - Street 2:GARDEN STATE ORTHOPAEDIC ASSOCIATES
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3913
Mailing Address - Country:US
Mailing Address - Phone:201-791-4434
Mailing Address - Fax:
Practice Address - Street 1:28-04 BROADWAY
Practice Address - Street 2:GARDEN STATE ORTHOPAEDIC ASSOCIATES
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3913
Practice Address - Country:US
Practice Address - Phone:201-791-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05941700207X00000X, 207XX0005X
NJ25MA0941700207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5596408Medicaid
NJE20173Medicare UPIN
NJ5596408Medicaid
200022883Medicare PIN