Basic Information
Provider Information | |||||||||
NPI: | 1992861751 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUI | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | LEWIS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEWIS | ||||||||
OtherFirstName: | COURTNEY | ||||||||
OtherMiddleName: | BAIN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4420 LAKE BOONE TRL STE 120 | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276077505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197843018 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4420 LAKE BOONE TRL STE 120 | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276077505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197843018 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2006 | ||||||||
LastUpdateDate: | 03/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | D69615 | MD | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | MT182964 | PA | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | MD427420 | PA | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 2012-01591 | NC | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | D69615 | 01 | MD | STATE LICENSE | OTHER |