Provider Demographics
NPI:1508846866
Name:LEWERENZ-WALSH, AUDREY A (DO)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:A
Last Name:LEWERENZ-WALSH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 MANATEE AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-2550
Mailing Address - Country:US
Mailing Address - Phone:941-748-8069
Mailing Address - Fax:941-748-6609
Practice Address - Street 1:3303 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-2550
Practice Address - Country:US
Practice Address - Phone:941-748-8069
Practice Address - Fax:941-748-6609
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0004817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00307FLOtherANTHEM BCBS
1730243841OtherTRICARE
143683OtherSTAYWELL HEALLTHY KIDS PROVIDER
4315059OtherAETNA HMO
08004770OtherRAILROAD MEDICARE
0622723OtherAETNA
FL064822100Medicaid
4285521OtherCIGNA
08004770OtherRAILROAD MEDICARE
FLE32290Medicare UPIN