Basic Information
| Provider Information | |||||||||
| NPI: | 1760463194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23625 COMMERCE PARK | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555701 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Practice Location | |||||||||
| Address1: | 6920 CORTE LANGOSTA | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920096094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555700 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | G50433 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | G50433 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 523625428 | 05 | NE | MEDICAID | 73383302 | 05 | AZ | MEDICAID | 00G504330 | 05 | CA | MEDICAID | 1016646250001 | 05 | PA | MEDICAID | 7705910 | 05 | SD | MEDICAID | 00G504330 | 01 | CA | BCBS | OTHER | 300135801 | 01 | CA | RXR MEDICARE | OTHER | 806430800 | 05 | ID | MEDICAID | 2309219 | 05 | OH | MEDICAID | 0067496 | 05 | MT | MEDICAID |