Provider Demographics
NPI:1093934036
Name:LEWIS, MICHAEL ROBIN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBIN
Last Name:LEWIS
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 1:20315 VENTURA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2449
Mailing Address - Country:US
Mailing Address - Phone:818-658-3830
Mailing Address - Fax:747-900-6961
Practice Address - Street 1:20315 VENTURA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2449
Practice Address - Country:US
Practice Address - Phone:818-658-3830
Practice Address - Fax:747-900-6961
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ54049YOtherBS/TRIWEST
CA1093934036Medicaid
CA00A1038520Medicaid
CA1316113145Medicaid
CAAS792ZMedicare PIN
CA1316113145Medicaid
CAAS743AMedicare PIN