Provider Demographics
NPI:1154307296
Name:DISNEY, LEW BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:LEW
Middle Name:BRADLEY
Last Name:DISNEY
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 1:255 E BONITA AVE
Mailing Address - Street 2:BUILDING #9
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1923
Mailing Address - Country:US
Mailing Address - Phone:909-450-0369
Mailing Address - Fax:909-450-0366
Practice Address - Street 1:255 E BONITA AVE
Practice Address - Street 2:BUILDING #9
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-450-0369
Practice Address - Fax:909-450-0366
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49362207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0099730Medicaid
CAWA49362BMedicare PIN
CAGR0099730Medicaid
CAE99296Medicare UPIN
CA00A493622Medicare PIN