Provider Demographics
NPI:1386722437
Name:LEVINSON, MICHAEL BRUCE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRUCE
Last Name:LEVINSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703
Mailing Address - Country:US
Mailing Address - Phone:631-242-0808
Mailing Address - Fax:631-274-3683
Practice Address - Street 1:1146 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703
Practice Address - Country:US
Practice Address - Phone:631-242-0808
Practice Address - Fax:631-274-3683
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003111152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00396754Medicaid
NY0619690001Medicare NSC
C25721Medicare ID - Type Unspecified
T48924Medicare UPIN