Healthcare Provider Details

I. General information

NPI: 1689470122
Provider Name (Legal Business Name): RUSS L LEVITAN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SANTA ROSA ST # 201
SAN LUIS OBISPO CA
93405-5826
US

IV. Provider business mailing address

1305 FILAREE WAY
ARROYO GRANDE CA
93420-4947
US

V. Phone/Fax

Practice location:
  • Phone: 805-544-7246
  • Fax: 805-782-8097
Mailing address:
  • Phone: 805-550-0445
  • Fax: 805-782-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: RUSS L LEVITAN
Title or Position: PRESIDENT
Credential: MD
Phone: 805-550-0445