Provider Demographics
NPI:1639369150
Name:LEVINE, JUSTIN J (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
Last Name:LEVINE
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:PO BOX 840
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-0840
Mailing Address - Country:US
Mailing Address - Phone:877-574-7116
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:333 LAIDLEY ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1614
Practice Address - Country:US
Practice Address - Phone:304-343-4625
Practice Address - Fax:304-343-4626
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD194492085R0202X
WV300902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0440726Medicaid
WV1639369150Medicaid