Provider Demographics
NPI:1770657090
Name:LEWIS, BRIAN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:B.
Other - Middle Name:DOUGLAS
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3351 EL CAMINO REAL STE 205
Mailing Address - Street 2:
Mailing Address - City:ATHERTON
Mailing Address - State:CA
Mailing Address - Zip Code:94027-3864
Mailing Address - Country:US
Mailing Address - Phone:650-364-3600
Mailing Address - Fax:
Practice Address - Street 1:3351 EL CAMINO REAL STE 205
Practice Address - Street 2:
Practice Address - City:ATHERTON
Practice Address - State:CA
Practice Address - Zip Code:94027-3864
Practice Address - Country:US
Practice Address - Phone:650-364-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG483562085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G483560Medicare ID - Type Unspecified
A93917Medicare UPIN