Provider Demographics
NPI:1073616363
Name:WEISBLUM, LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:
Last Name:WEISBLUM
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 1:1200 B GALE WILSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3552
Mailing Address - Country:US
Mailing Address - Phone:707-646-5110
Mailing Address - Fax:
Practice Address - Street 1:1200 B GALE WILSON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3552
Practice Address - Country:US
Practice Address - Phone:707-646-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG525082085R0202X
NY1811252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology