Provider Demographics
NPI:1255458055
Name:LEVISAY, JUSTIN PAUL
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:PAUL
Last Name:LEVISAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CENTRAL ST STE 730
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1779
Mailing Address - Country:US
Mailing Address - Phone:847-663-8410
Mailing Address - Fax:847-676-1727
Practice Address - Street 1:1000 CENTRAL ST STE 730
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-663-8410
Practice Address - Fax:847-676-1727
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105254207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease