Provider Demographics
NPI:1871773705
Name:LEWIS, BRIAN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3532 UPPERLINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-4816
Mailing Address - Country:US
Mailing Address - Phone:504-218-8010
Mailing Address - Fax:
Practice Address - Street 1:3532 UPPERLINE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125-4816
Practice Address - Country:US
Practice Address - Phone:504-218-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1215490Medicaid
LA4Q192Medicare PIN