Healthcare Provider Details

I. General information

NPI: 1992783302
Provider Name (Legal Business Name): RUSS LLOYD LEVITAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SANTA ROSA ST STE 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 TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG58508
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG58508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: