Healthcare Provider Details

I. General information

NPI: 1689936569
Provider Name (Legal Business Name): MARK DAVID LEVINE MD, PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 PICASSO AVE SUITE D
DAVIS CA
95618
US

IV. Provider business mailing address

2081 ARENA BLVD SUITE 160
SACRAMENTO CA
95834-2309
US

V. Phone/Fax

Practice location:
  • Phone: 530-297-7500
  • Fax: 530-297-7751
Mailing address:
  • Phone: 916-576-7898
  • Fax: 916-285-0338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK DAVID LEVINE
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 916-576-7898