Provider Demographics
NPI:1891783643
Name:LEVINE, MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LEVINE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 TIMBERLINE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06057-3324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38 TIMBERLINE RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06057-3324
Practice Address - Country:US
Practice Address - Phone:860-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT851111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004099306Medicaid
CT004099306Medicaid
CT350001317Medicare PIN