Provider Demographics
NPI:1841221256
Name:LEWIS J HERZBRUN MD PA
Entity Type:Organization
Organization Name:LEWIS J HERZBRUN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERZBRUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-357-7342
Mailing Address - Street 1:PO BOX 1507
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32727-1507
Mailing Address - Country:US
Mailing Address - Phone:352-357-7342
Mailing Address - Fax:352-357-7395
Practice Address - Street 1:30 W WILT AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-2949
Practice Address - Country:US
Practice Address - Phone:352-357-7342
Practice Address - Fax:352-357-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73067208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252214400Medicaid
AD872Medicare PIN
FLG51969Medicare UPIN