Provider Demographics
NPI:1659304590
Name:LEVENSON, JEREMY ETHAN (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ETHAN
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 1:6654 KENTWOOD BLUFFS DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1259
Mailing Address - Country:US
Mailing Address - Phone:310-216-4476
Mailing Address - Fax:
Practice Address - Street 1:2125 ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1337
Practice Address - Country:US
Practice Address - Phone:310-829-8701
Practice Address - Fax:310-315-4062
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22502207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00178725OtherRAILROAD MEDICARE
CA00A225020Medicaid
CAA22502Medicare ID - Type Unspecified
CAA23105Medicare UPIN