Provider Demographics
NPI:1982625000
Name:LEVINSON, ILAN S (MD)
Entity Type:Individual
Prefix:
First Name:ILAN
Middle Name:S
Last Name:LEVINSON
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 1:1172 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360
Mailing Address - Country:US
Mailing Address - Phone:570-424-6187
Mailing Address - Fax:570-424-6271
Practice Address - Street 1:1172 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360
Practice Address - Country:US
Practice Address - Phone:570-424-6187
Practice Address - Fax:570-424-6271
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD055185L2084P0800X
PAMD01855L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015426100005Medicaid
PA001542610000SMedicaid
PA0000789615OtherHIGHMARK
PA0015426100005Medicaid
PAG10833Medicare UPIN
G10833Medicare UPIN