Provider Demographics
NPI:1053404806
Name:LEVIN, DANIEL JOHN (OD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:LEVIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EAST THIRD STREET
Mailing Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC MCL2CRED
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-1183
Mailing Address - Fax:
Practice Address - Street 1:1100 19TH AVE N STE L&M
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-5906
Practice Address - Country:US
Practice Address - Phone:701-365-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND473152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160525900Medicaid
NDN10366OtherBCBS ND
ND60422Medicaid
ND60422Medicaid