Provider Demographics
NPI:1366534018
Name:HERRIET V TUPAS LEVITAN MD PA
Entity type:Organization
Organization Name:HERRIET V TUPAS LEVITAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERRIET
Authorized Official - Middle Name:V
Authorized Official - Last Name:TUPAS LEVITAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:407-645-4441
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32790
Mailing Address - Country:US
Mailing Address - Phone:407-645-4441
Mailing Address - Fax:407-645-3242
Practice Address - Street 1:1925 MIZELL AVENUE
Practice Address - Street 2:SUITE #301
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792
Practice Address - Country:US
Practice Address - Phone:407-645-4441
Practice Address - Fax:407-645-3242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047659500Medicaid
FL04829Medicare ID - Type Unspecified
FL047659500Medicaid