Healthcare Provider Details

I. General information

NPI: 1952862468
Provider Name (Legal Business Name): ADAM G LEVIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 N SHOOP AVE
WAUSEON OH
43567-1821
US

IV. Provider business mailing address

4235 SECOR RD
TOLEDO OH
43623-4299
US

V. Phone/Fax

Practice location:
  • Phone: 419-330-5200
  • Fax:
Mailing address:
  • Phone: 419-479-5795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number34.016538
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5101027433
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPTL1315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: