Provider Demographics
NPI:1760412399
Name:LEVY, J RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:RICHARD
Last Name:LEVY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BELLEROSA CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3358
Mailing Address - Country:US
Mailing Address - Phone:314-821-2925
Mailing Address - Fax:314-821-2991
Practice Address - Street 1:5 BELLEROSA CT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3358
Practice Address - Country:US
Practice Address - Phone:314-821-2925
Practice Address - Fax:314-821-2991
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist