Provider Demographics
NPI:1205093242
Name:LEVINE, BRUCE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24670 GOTHAM STREET RD
Mailing Address - Street 2:CARRIAGE HOUSE
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4290
Mailing Address - Country:US
Mailing Address - Phone:303-385-7368
Mailing Address - Fax:
Practice Address - Street 1:24670 GOTHAM STREET RD
Practice Address - Street 2:CARRIAGE HOUSE
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4290
Practice Address - Country:US
Practice Address - Phone:303-385-7368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO467582084P0804X
NY2426582084P0804X
WATD606326552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50385755Medicaid
COCO301741Medicare PIN