Provider Demographics
NPI:1730206509
Name:LEVINE, JOHN BRAVERMAN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BRAVERMAN
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1105 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5220
Mailing Address - Country:US
Mailing Address - Phone:617-491-8022
Mailing Address - Fax:617-441-8643
Practice Address - Street 1:1105 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 3D
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5220
Practice Address - Country:US
Practice Address - Phone:617-491-8022
Practice Address - Fax:617-441-8643
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2011-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA589492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA32018Medicare ID - Type Unspecified
MAF14019Medicare UPIN