Provider Demographics
NPI:1063823540
Name:LEWIS, EDGAR III (CO)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:LEWIS
Suffix:III
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16988 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-2973
Mailing Address - Country:US
Mailing Address - Phone:248-227-1408
Mailing Address - Fax:
Practice Address - Street 1:16988 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2973
Practice Address - Country:US
Practice Address - Phone:248-227-1408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICO0004213335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier