Provider Demographics
NPI:1558527572
Name:PO LONG LEW, D.O. A MEDICAL PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:PO LONG LEW, D.O. A MEDICAL PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PO
Authorized Official - Middle Name:LONG
Authorized Official - Last Name:LEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-288-8881
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:
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX53801Medicaid
CA20A5380AMedicare PIN
CA00AX53801Medicaid