Provider Demographics
NPI:1235145350
Name:LEW, PO LONG (DO)
Entity Type:Individual
Prefix:
First Name:PO
Middle Name:LONG
Last Name:LEW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9308 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-1924
Mailing Address - Country:US
Mailing Address - Phone:626-288-8881
Mailing Address - Fax:626-288-6648
Practice Address - Street 1:9308 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-1924
Practice Address - Country:US
Practice Address - Phone:626-288-8881
Practice Address - Fax:626-288-6648
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX53801Medicaid
CA20A5380AOtherMEDICARE
CA00AX53800Medicaid
CA00AX53801Medicaid
CA20A5380Medicare ID - Type Unspecified