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General NPI Number Information
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NPI Number | 1205093242
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Entity Type | Individual
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Provider Name | BRUCE LEVINE MD
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Gender | Male
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Dates
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Enumeration Date | 05/19/2008
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Last Update Date | 11/15/2016
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Provider Practice Location Address
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Address Line | 24670 GOTHAM STREET RD CARRIAGE HOUSE
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City | WATERTOWN
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State | NY
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Zip | 13601-4290
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Country | US
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Telephone | 303-385-7368
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Fax |
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Provider Business Mailing Address
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Address Line | 24670 GOTHAM STREET RD CARRIAGE HOUSE
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City | WATERTOWN
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State | NY
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Zip | 13601-4290
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Country | US
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Telephone | 303-385-7368
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 46758
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 242658
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | TD60632655
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License Number State | WA
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