Provider Demographics
NPI:1023277464
Name:LEVI, MICHAEL IRA (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:IRA
Last Name:LEVI
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 1:610 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2154
Mailing Address - Country:US
Mailing Address - Phone:315-281-4485
Mailing Address - Fax:
Practice Address - Street 1:1614 N JAMES ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2830
Practice Address - Country:US
Practice Address - Phone:315-339-7411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217243207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02086602Medicaid