Provider Demographics
NPI:1760470546
Name:LEVINE, ELLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLYN
Middle Name:
Last Name:LEVINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 VALLEY CENTRE DR
Mailing Address - Street 2:UNIT 705-306
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3320
Mailing Address - Country:US
Mailing Address - Phone:619-567-6914
Mailing Address - Fax:619-567-6916
Practice Address - Street 1:5290 BALTIMORE DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2080
Practice Address - Country:US
Practice Address - Phone:619-567-6914
Practice Address - Fax:619-567-6916
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86297207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF77273Medicare UPIN