Healthcare Provider Details

I. General information

NPI: 1306266770
Provider Name (Legal Business Name): WILLIAM LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2496 BAUER RD
SAN DIEGO CA
92145-0001
US

IV. Provider business mailing address

2496 BAUER RD
SAN DIEGO CA
92145-0001
US

V. Phone/Fax

Practice location:
  • Phone: 858-307-9907
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101258911
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: