Provider Demographics
NPI:1710960927
Name:LEVAN, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LEVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YELENA
Other - Middle Name:
Other - Last Name:ITSKHOKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:26-01 PELLACK DRIVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-791-9340
Mailing Address - Fax:201-791-9481
Practice Address - Street 1:26-01 PELLACK DRIVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-791-9340
Practice Address - Fax:201-791-9481
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07184800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01696226Medicaid
NY305511Medicare ID - Type Unspecified
NY01696226Medicaid