Provider Demographics
NPI:1184617813
Name:LEVINE, MICHAEL JAY (M D)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:LEVINE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 W CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-5916
Mailing Address - Country:US
Mailing Address - Phone:559-625-5833
Mailing Address - Fax:559-625-5418
Practice Address - Street 1:914 W CENTER AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5916
Practice Address - Country:US
Practice Address - Phone:559-625-5833
Practice Address - Fax:559-625-5418
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG18859208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G188590Medicaid
CA00G188590Medicaid