Healthcare Provider Details

I. General information

NPI: 1750301065
Provider Name (Legal Business Name): SUSAN L LEWIS M.D,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 OLD SAN FRANCISCO RD
SUNNYVALE CA
94086-6387
US

IV. Provider business mailing address

2350 W EL CAMINO REAL FL 2
MOUNTAIN VIEW CA
94040-6203
US

V. Phone/Fax

Practice location:
  • Phone: 650-934-7111
  • Fax:
Mailing address:
  • Phone:
  • Fax: 415-493-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberG078780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: