Healthcare Provider Details

I. General information

NPI: 1205260817
Provider Name (Legal Business Name): MARSHALL S. LEWIS, MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 W HERNDON AVE
FRESNO CA
93711-7118
US

IV. Provider business mailing address

2619 F ST
BAKERSFIELD CA
93301-1815
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-1145
  • Fax: 559-439-1345
Mailing address:
  • Phone: 661-861-0011
  • Fax: 661-861-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC30003
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC9103
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15629
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberMC2665214
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG282420
License Number StateCA

VIII. Authorized Official

Name: MRS. DIANA A GALVAN
Title or Position: CREDENTIALER
Credential: RMA
Phone: 661-861-0011