Provider Demographics
NPI:1881814549
Name:LEVINE, BRIAN J (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
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:PO BOX 43160
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3160
Mailing Address - Country:US
Mailing Address - Phone:520-722-3777
Mailing Address - Fax:520-296-6224
Practice Address - Street 1:1712 W ANKLAM RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2660
Practice Address - Country:US
Practice Address - Phone:520-622-7384
Practice Address - Fax:520-622-4899
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ36043208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ222087Medicaid
AZ222061Medicaid
AZ36043OtherAZ MEDICAL LIC
AZ36043OtherAZ MEDICAL LIC
AZ222087Medicaid