Provider Demographics
NPI:1487654489
Name:LEWIS, BRANDON J (DPM)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 N CARRIER PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-5428
Mailing Address - Country:US
Mailing Address - Phone:972-263-7042
Mailing Address - Fax:972-263-7046
Practice Address - Street 1:504 N CARRIER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5428
Practice Address - Country:US
Practice Address - Phone:972-263-7042
Practice Address - Fax:972-263-7046
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1574213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00820670OtherGROUP MEMBER INDIVIDUAL RRM PTAN #
TX8U9330OtherBCBS
TX161998302Medicaid
TX161998302Medicaid
U95366Medicare UPIN
TX8U9330OtherBCBS
TX8L12563Medicare PIN