Provider Demographics
NPI:1700885407
Name:LEVAN, DEBORAH JO (DO)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JO
Last Name:LEVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11885 E 12 MILE RD
Mailing Address - Street 2:SUITE #300A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3474
Mailing Address - Country:US
Mailing Address - Phone:586-582-6791
Mailing Address - Fax:586-582-6792
Practice Address - Street 1:11885 E 12 MILE RD
Practice Address - Street 2:SUTIE #300A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3474
Practice Address - Country:US
Practice Address - Phone:586-582-6791
Practice Address - Fax:586-582-6792
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007248207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI417185711Medicaid
MI700H270060OtherBCBSM
MIB44567Medicare UPIN
MI700H270060OtherBCBSM
MIN71840056Medicare PIN
MIM71670173Medicare PIN