Provider Demographics
NPI:1033116017
Name:LEWIS, HERSEL (OD)
Entity Type:Individual
Prefix:
First Name:HERSEL
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9700 S MCCARRAN BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-9203
Mailing Address - Country:US
Mailing Address - Phone:775-827-3937
Mailing Address - Fax:
Practice Address - Street 1:276 KINGSBURY GRADE # 103
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-9804
Practice Address - Country:US
Practice Address - Phone:775-588-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2345T152W00000X
NV939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR071115000OtherREGENCE BLUE CROSS
U48442Medicare UPIN
OR115000658MCMedicare ID - Type Unspecified