Provider Demographics
NPI:1689761926
Name:LEVINE, EDWARD J (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
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 1:1491 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2311
Mailing Address - Country:US
Mailing Address - Phone:718-273-6999
Mailing Address - Fax:718-273-4394
Practice Address - Street 1:1491 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2311
Practice Address - Country:US
Practice Address - Phone:718-273-6999
Practice Address - Fax:718-273-4394
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152068261QP2300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00991635Medicaid
NYC12128Medicare UPIN
NYA100031575Medicare Oscar/Certification