Provider Demographics
NPI:1124053830
Name:LEWIS, GENA LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GENA
Middle Name:LEE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1033
Mailing Address - Country:US
Mailing Address - Phone:510-428-3885
Mailing Address - Fax:510-547-2702
Practice Address - Street 1:5220 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1033
Practice Address - Country:US
Practice Address - Phone:510-428-3885
Practice Address - Fax:510-547-2702
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA061397208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095800Medicaid
CA680572143OtherFEDERAL TAX ID NO. INPATI
CA542125582OtherFEDERAL TAX ID NO.-OUTPAT