Provider Demographics
NPI:1033115803
Name:LEWIS, KIRK J (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
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 1:1188 W UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3009
Mailing Address - Country:US
Mailing Address - Phone:208-336-8250
Mailing Address - Fax:208-345-9514
Practice Address - Street 1:1188 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-336-8250
Practice Address - Fax:208-345-9514
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4960207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1033115803Medicaid
ID000010003204OtherREGENCE BLUE SHIELD#
ID000010003204OtherREGENCE BLUE SHIELD#
IDC36953Medicare UPIN