Provider Demographics
NPI:1710094750
Name:LEVIN, BRUCE ALAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:LEVIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 RENNARD TERRACE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2605
Mailing Address - Country:US
Mailing Address - Phone:215-260-8654
Mailing Address - Fax:215-969-6549
Practice Address - Street 1:410 E ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-4011
Practice Address - Country:US
Practice Address - Phone:215-260-8654
Practice Address - Fax:215-969-6549
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001718L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0501865Medicaid
PA31774OtherKEYSTONE MERCY HLTH PLAN
PA0501865Medicaid
137748Medicare ID - Type Unspecified