Healthcare Provider Details

I. General information

NPI: 1154493476
Provider Name (Legal Business Name): FRED LEVINE M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FROST ST STE 200
SAN DIEGO CA
92123-2771
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC5110
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-7800
  • Fax:
Mailing address:
  • Phone: 619-543-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberG65341
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License NumberG65341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: