Healthcare Provider Details

I. General information

NPI: 1265099139
Provider Name (Legal Business Name): JARED JAREAUX LEVINGSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 BATTERSON PARK RD STE 106
FARMINGTON CT
06032-2571
US

IV. Provider business mailing address

17714 FAIRHAVEN GATEWAY DR
CYPRESS TX
77433-3570
US

V. Phone/Fax

Practice location:
  • Phone: 203-879-0834
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125074023
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number295172
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: