Provider Demographics
NPI:1396731899
Name:LEVIN, JON I (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:I
Last Name:LEVIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1399 WEIMER RD
Mailing Address - Street 2:SUITE # 600
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6340
Mailing Address - Country:US
Mailing Address - Phone:575-751-0334
Mailing Address - Fax:575-751-0297
Practice Address - Street 1:1399 WEIMER RD
Practice Address - Street 2:SUITE # 600
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6340
Practice Address - Country:US
Practice Address - Phone:575-751-0334
Practice Address - Fax:575-751-0297
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-926-91208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
11348824OtherCAQH
11348824OtherCAQH