Provider Demographics
NPI:1871609222
Name:LEWIS, BRADLEY K (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:K
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1126 DRAPER PKWY
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9095
Mailing Address - Country:US
Mailing Address - Phone:801-545-0600
Mailing Address - Fax:801-545-0626
Practice Address - Street 1:1126 DRAPER PKWY
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9095
Practice Address - Country:US
Practice Address - Phone:801-545-0600
Practice Address - Fax:801-545-0626
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT94-277413-1205207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870639098001Medicaid
UT870639098001Medicaid
UT005749003Medicare ID - Type Unspecified