Basic Information
| Provider Information | |||||||||
| NPI: | 1699770172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVITCH | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 PARVIN DR | ||||||||
| Address2: | |||||||||
| City: | PITTSGROVE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083184020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093351679 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | JIMMY LEEDS RD | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096521000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA04464700 | NJ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1657909 | 05 | NJ | MEDICAID |