Provider Demographics
NPI:1164452157
Name:HERZBRUN, LEWIS JACKSON (MD)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:JACKSON
Last Name:HERZBRUN
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 1507
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32727-1507
Mailing Address - Country:US
Mailing Address - Phone:352-357-7342
Mailing Address - Fax:352-357-7395
Practice Address - Street 1:30 W WILT AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-2949
Practice Address - Country:US
Practice Address - Phone:352-357-7342
Practice Address - Fax:352-357-7395
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73067208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25221400Medicaid
FL41870WMedicare PIN
FLG51969Medicare UPIN