Provider Demographics
NPI:1679648968
Name:LEVIN, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:LEVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5128
Mailing Address - Country:US
Mailing Address - Phone:516-766-0550
Mailing Address - Fax:516-766-0585
Practice Address - Street 1:560 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5128
Practice Address - Country:US
Practice Address - Phone:516-766-0550
Practice Address - Fax:516-766-0585
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU61489Medicare UPIN