Provider Demographics
NPI:1689638454
Name:LEVINE, MARIANNE ROSE (DO)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:ROSE
Last Name:LEVINE
Suffix:
Gender:F
Credentials:DO
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 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-2363
Mailing Address - Fax:817-735-2653
Practice Address - Street 1:3440 CAMP BOWIE BOULEVARD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2729
Practice Address - Country:US
Practice Address - Phone:817-735-2363
Practice Address - Fax:817-735-2653
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87761GOtherBCBS
TX134206505Medicaid
TX370014522OtherRAILROAD MEDICARE PIN
TX134206507OtherCSHCN
TX87761GOtherBCBS
TX134206507OtherCSHCN