Provider Demographics
NPI:1912089814
Name:LEVINE, JACK (OD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LEVINE
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 1:120 MEYER RD
Mailing Address - Street 2:#523
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1046
Mailing Address - Country:US
Mailing Address - Phone:716-834-6399
Mailing Address - Fax:
Practice Address - Street 1:2064 SENECA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-2343
Practice Address - Country:US
Practice Address - Phone:716-822-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV002844-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00610619Medicaid
NY00610619Medicaid