Provider Demographics
NPI:1053621078
Name:LEVINE, MATHEW (DO)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:
Last Name:LEVINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6012
Mailing Address - Country:US
Mailing Address - Phone:770-886-8111
Mailing Address - Fax:770-205-8539
Practice Address - Street 1:1100 NORTHSIDE FORSYTH DR
Practice Address - Street 2:SUITE 340
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6012
Practice Address - Country:US
Practice Address - Phone:770-886-8111
Practice Address - Fax:770-205-8539
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT013214390200000X
PAOS015919207X00000X
ARE-8622207X00000X
GA074072207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003167726BMedicaid
GA003167726AMedicaid
GA003167726BMedicaid