1285722983 NPI number — LISA E LEWIS MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285722983 NPI number — LISA E LEWIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
LISA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EHL
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285722983
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 N RUFE SNOW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KELLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76248-4226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-337-5503
Provider Business Mailing Address Fax Number:
817-337-0110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6618 FOSSIL BLUFF DR
Provider Second Line Business Practice Location Address:
STE 116
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76137-7533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-847-6420
Provider Business Practice Location Address Fax Number:
817-847-6412
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  K0730 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1164541967 . This is a "FORT WORTH GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 047946102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1710006598 . This is a "KELLER GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0046KV . This is a "BCBS GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8K6666 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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