1255385779 NPI number — DR. MARY BETH LEWIS-BOARDMAN MD

Table of content: DR. MARY BETH LEWIS-BOARDMAN MD (NPI 1255385779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255385779 NPI number — DR. MARY BETH LEWIS-BOARDMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS-BOARDMAN
Provider First Name:
MARY BETH
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
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:
1255385779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16921 FLORENCE VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTVERDE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34756-3423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-348-3008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 S CHILDS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-5922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-348-3008
Provider Business Practice Location Address Fax Number:
352-432-1479
Provider Enumeration Date:
05/20/2006

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: 207VG0400X , with the licence number:  ME93877 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018606200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com