Provider Demographics
NPI:1154418457
Name:LEVINE, JEFFREY MARK (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MARK
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4119 SE BYBEE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7743
Mailing Address - Country:US
Mailing Address - Phone:203-451-3570
Mailing Address - Fax:503-241-2367
Practice Address - Street 1:4119 SE BYBEE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7743
Practice Address - Country:US
Practice Address - Phone:203-451-3570
Practice Address - Fax:503-241-2367
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2194342084P0015X
MA458102084P0800X
CT330242084P0800X
CAG1534992084P0800X
ORMD1954762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic MedicineGroup - Multi-Specialty