Provider Demographics
NPI:1942368907
Name:SELF, LEWIS H (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:H
Last Name:SELF
Suffix:
Gender:M
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:PO BOX 231189
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92023-1189
Mailing Address - Country:US
Mailing Address - Phone:760-230-2252
Mailing Address - Fax:760-230-2253
Practice Address - Street 1:354 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5142
Practice Address - Country:US
Practice Address - Phone:760-230-2252
Practice Address - Fax:760-230-2253
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7570207R00000X
CAC50733207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019796Medicaid
NV002019796Medicaid
NV002019796Medicaid