Provider Demographics
NPI:1467530089
Name:LEWIS, BRIAN JOEL (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOEL
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 1:50 MATHER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1047
Mailing Address - Country:US
Mailing Address - Phone:415-454-2676
Mailing Address - Fax:
Practice Address - Street 1:50 MATHER RD
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-1047
Practice Address - Country:US
Practice Address - Phone:415-454-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26437207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G264370Medicaid
A43009Medicare UPIN
CA00G264370Medicaid