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General NPI Number Information
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NPI Number | 1073616363
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Entity Type | Individual
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Provider Name | LEWIS WEISBLUM M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/05/2006
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Last Update Date | 11/25/2015
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Provider Practice Location Address
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Address Line | 1200 B GALE WILSON BLVD
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City | FAIRFIELD
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State | CA
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Zip | 94533-3552
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Country | US
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Telephone | 707-646-5110
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 B GALE WILSON BLVD
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City | FAIRFIELD
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State | CA
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Zip | 94533-3552
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Country | US
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Telephone | 707-646-5110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | G52508
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 181125
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License Number State | NY
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