Provider Demographics
NPI:1790891570
Name:LEVINE, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1605
Mailing Address - Country:US
Mailing Address - Phone:585-473-4547
Mailing Address - Fax:
Practice Address - Street 1:200 WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1605
Practice Address - Country:US
Practice Address - Phone:585-473-4547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200197207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD03645Medicare UPIN