Provider Demographics
NPI:1962577080
Name:LEVISTER, ERNEST CLAYTON JR (MD)
Entity type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:CLAYTON
Last Name:LEVISTER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1738 N WATERMAN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5135
Mailing Address - Country:US
Mailing Address - Phone:909-883-8683
Mailing Address - Fax:909-883-4324
Practice Address - Street 1:1738 N WATERMAN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5135
Practice Address - Country:US
Practice Address - Phone:909-883-8683
Practice Address - Fax:909-883-4324
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG018549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A40366Medicare UPIN