Provider Demographics
NPI:1043453228
Name:LEWIS, JASON (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAPEL
Practice Address - State:IN
Practice Address - Zip Code:46051-9671
Practice Address - Country:US
Practice Address - Phone:765-534-3127
Practice Address - Fax:765-534-3022
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01070104A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01157055OtherRR MEDICARE PTAN
IN201067400Medicaid
INP01157055OtherRR MEDICARE PTAN