Provider Demographics
NPI:1174039333
Name:LEWIS WYATT JR. M.D. INC.
Entity type:Organization
Organization Name:LEWIS WYATT JR. M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT JR.
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-360-7430
Mailing Address - Street 1:2061 WESTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-1805
Mailing Address - Country:US
Mailing Address - Phone:310-360-7430
Mailing Address - Fax:310-360-7435
Practice Address - Street 1:99 N LA CIENEGA BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2222
Practice Address - Country:US
Practice Address - Phone:310-360-7430
Practice Address - Fax:310-360-7430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C320300207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFSW794AMedicaid
CA14078963127Medicaid
CAFS794AOtherPTAN