Provider Demographics
NPI:1760456529
Name:LEWIS, BEVERLY (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29306 CATALPA
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-9100
Mailing Address - Country:US
Mailing Address - Phone:310-806-1002
Mailing Address - Fax:
Practice Address - Street 1:900 S MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3401
Practice Address - Country:US
Practice Address - Phone:951-363-0243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42697208D00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0040370Medicaid
A49076Medicare UPIN
CAGR0040370Medicaid