Provider Demographics
NPI:1992783302
Name:LEVITAN, RUSS LLOYD (MD)
Entity type:Individual
Prefix:
First Name:RUSS
Middle Name:LLOYD
Last Name:LEVITAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 FILAREE WAY
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-4947
Mailing Address - Country:US
Mailing Address - Phone:805-550-0445
Mailing Address - Fax:805-782-8097
Practice Address - Street 1:10 SANTA ROSA ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5826
Practice Address - Country:US
Practice Address - Phone:805-544-7246
Practice Address - Fax:805-782-8097
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58508207LP2900X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE02849Medicare UPIN
CAWG58508AMedicare ID - Type Unspecified