Provider Demographics
NPI:1306999164
Name:LEWIS, ROGER J (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:J
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 1:27603 SUNNYRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-4042
Mailing Address - Country:US
Mailing Address - Phone:310-720-1661
Mailing Address - Fax:424-667-2125
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 480
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-6741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63560207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G635600Medicaid
CAWG63560EMedicare ID - Type UnspecifiedPPIN
CAE17559Medicare UPIN
CA00G635600Medicaid