Provider Demographics
NPI:1033115910
Name:BADER, LEWIS M (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:M
Last Name:BADER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6128
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-0128
Mailing Address - Country:US
Mailing Address - Phone:203-683-4500
Mailing Address - Fax:203-926-1410
Practice Address - Street 1:2660 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5369
Practice Address - Country:US
Practice Address - Phone:203-683-4540
Practice Address - Fax:203-926-1415
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0159872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001159870Medicaid
CT300001912Medicare ID - Type UnspecifiedMEDICARE
CT001159870Medicaid