Provider Demographics
NPI:1912971250
Name:LEVINE, MICHAEL IRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:IRA
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 1:1434 WILLIAMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2507
Mailing Address - Country:US
Mailing Address - Phone:646-759-5453
Mailing Address - Fax:646-374-4940
Practice Address - Street 1:1434 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2507
Practice Address - Country:US
Practice Address - Phone:646-759-5453
Practice Address - Fax:646-374-4940
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169142207R00000X, 207RN0300X
WI38379174400000X
WI38379-020207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32303500Medicaid
NY01110109Medicaid
NY01110109Medicaid
WI32303500Medicaid
NY01110109Medicaid