Provider Demographics
NPI:1124096060
Name:LEWIS, BERTRAM A JR (MD, PHD MBA FACS)
Entity type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:A
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:MD, PHD MBA FACS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6748 GALL BLVD
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-2544
Mailing Address - Country:US
Mailing Address - Phone:813-779-1209
Mailing Address - Fax:813-779-1216
Practice Address - Street 1:6748 GALL BLVD
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-2544
Practice Address - Country:US
Practice Address - Phone:813-779-1209
Practice Address - Fax:813-779-1216
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9901570208800000X
AZ35491208800000X
FLME103274208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001360600Medicaid
AZ7661457OtherAETNA
AZ135924OtherHEALTH CHOICE ARIZONA
AZ135924Medicaid
FL6005682OtherCIGNA
AZ6005682OtherCIGNA
FL7661457OtherAETNA
FL330605OtherAVMED
AZAZ0921980OtherBCBS
FLP00793962OtherMEDICARE RAILROAD
AZ135924002OtherARIZONA PHYSICIANS IPA
FL1463HOtherBCBS
AZ2Z8105OtherHEALTH NET OF ARIZONA
FL529993OtherWELLCARE
AZAZ0921980OtherBCBS
AZ6005682OtherCIGNA
NCH83542Medicare UPIN
AZ135924Medicaid