Provider Demographics
NPI:1073615951
Name:LEWIS, MITZI HERNDON (OD)
Entity Type:Individual
Prefix:DR
First Name:MITZI
Middle Name:HERNDON
Last Name:LEWIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7307
Mailing Address - Country:US
Mailing Address - Phone:417-886-5444
Mailing Address - Fax:
Practice Address - Street 1:3440 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7307
Practice Address - Country:US
Practice Address - Phone:417-886-5444
Practice Address - Fax:417-886-6444
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002027878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310884705Medicaid
MOU98678Medicare UPIN
MO256378989Medicare ID - Type Unspecified