Provider Demographics
NPI:1790849669
Name:LEVY, BRUCE RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:RICHARD
Last Name:LEVY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 NORTHERN BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-336-2534
Mailing Address - Fax:516-773-4211
Practice Address - Street 1:1010 NORTHERN BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-336-2534
Practice Address - Fax:516-773-4211
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1170062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC05660Medicare UPIN
NY05907Medicare ID - Type Unspecified