=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063634434
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK N LEVIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1970 LAVER CT # 2
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94024-6767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-964-6314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1970 LAVER CT # 2
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94024-6767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-964-6314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | C32109
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------