Provider Demographics
NPI:1790774040
Name:LEVISON, DIANA
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:LEVISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 ELM ST
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-5406
Mailing Address - Country:US
Mailing Address - Phone:203-966-9593
Mailing Address - Fax:203-966-9473
Practice Address - Street 1:136 ELM ST
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5406
Practice Address - Country:US
Practice Address - Phone:203-966-9593
Practice Address - Fax:203-966-9473
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist