Provider Demographics
NPI:1679531628
Name:LEVINE, MARK ROGER (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROGER
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 1:1611 S GREEN RD
Mailing Address - Street 2:SUITE 306A
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4128
Mailing Address - Country:US
Mailing Address - Phone:219-291-9770
Mailing Address - Fax:216-297-0550
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:SUITE 306A
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4128
Practice Address - Country:US
Practice Address - Phone:219-291-9770
Practice Address - Fax:216-297-0550
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-02-9064-L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181315Medicaid
OH4015781Medicare ID - Type Unspecified
OHC00919Medicare UPIN