1093792665 NPI number — MR. VERNON THEODORE LEW RPH

Table of content: MR. VERNON THEODORE LEW RPH (NPI 1093792665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093792665 NPI number — MR. VERNON THEODORE LEW RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEW
Provider First Name:
VERNON
Provider Middle Name:
THEODORE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093792665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 LISER GLN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78257-1377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-481-8442
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 BERGQUIST DR
Provider Second Line Business Practice Location Address:
BLDG 8410
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78236-9907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-292-8418
Provider Business Practice Location Address Fax Number:
210-292-7207
Provider Enumeration Date:
12/27/2005

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: 1835N1003X , with the licence number:  24525 , 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)





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