Healthcare Provider Details

I. General information

NPI: 1760456529
Provider Name (Legal Business Name): BEVERLY LEWIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S MAIN ST STE 105
CORONA CA
92882-3401
US

IV. Provider business mailing address

29306 CATALPA
LAKE ELSINORE CA
92530-9100
US

V. Phone/Fax

Practice location:
  • Phone: 951-363-0243
  • Fax:
Mailing address:
  • Phone: 310-806-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG42697
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG42697
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: