Provider Demographics
NPI:1528027836
Name:LEW, EDMUND H (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:H
Last Name:LEW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 WILSON TER
Mailing Address - Street 2:STE. 250
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4071
Mailing Address - Country:US
Mailing Address - Phone:818-246-7115
Mailing Address - Fax:818-246-8352
Practice Address - Street 1:1505 WILSON TER
Practice Address - Street 2:STE. 250
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4071
Practice Address - Country:US
Practice Address - Phone:818-246-7115
Practice Address - Fax:818-246-8352
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG55213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G552130Medicaid
CAD71811Medicare UPIN
CAG55213Medicare ID - Type UnspecifiedFAMILY PRACTICE