Healthcare Provider Details

I. General information

NPI: 1013168491
Provider Name (Legal Business Name): B. DOUGLAS LEWIS, M.D., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 10/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 EL CAMINO REAL STE 205
ATHERTON CA
94027-3864
US

IV. Provider business mailing address

3351 EL CAMINO REAL STE 205
ATHERTON CA
94027-3864
US

V. Phone/Fax

Practice location:
  • Phone: 650-364-3600
  • Fax: 650-364-3609
Mailing address:
  • Phone: 650-364-3600
  • Fax: 650-364-3609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberG48356
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberG48356
License Number StateCA

VIII. Authorized Official

Name: BRIAN DOUGLAS LEWIS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 650-364-3600