Provider Demographics
NPI:1073905386
Name:MARK A LEWIS, MD
Entity Type:Organization
Organization Name:MARK A LEWIS, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-639-0516
Mailing Address - Street 1:1 WIDGER RD
Mailing Address - Street 2:308
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-2146
Mailing Address - Country:US
Mailing Address - Phone:781-639-0516
Mailing Address - Fax:781-639-4191
Practice Address - Street 1:1 WIDGER RD
Practice Address - Street 2:308
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2146
Practice Address - Country:US
Practice Address - Phone:781-639-0516
Practice Address - Fax:781-639-4191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44331207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2070561Medicaid
MAD17046Medicare PIN