Provider Demographics
NPI:1295724631
Name:LEVINE, JEFFREY D (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
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 1:372 CHANDLER ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602
Mailing Address - Country:US
Mailing Address - Phone:508-752-4669
Mailing Address - Fax:508-767-1897
Practice Address - Street 1:372 CHANDLER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602
Practice Address - Country:US
Practice Address - Phone:508-752-4669
Practice Address - Fax:508-767-1897
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48153207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4020015OtherAETNA
MA0152463Medicaid
N01936OtherBCBS
048153OtherTUFTS
15504OtherHPHC
999510OtherNETWORK HEALTH
0004191OtherNHP
15504OtherHPHC
N01936Medicare ID - Type Unspecified