Provider Demographics
NPI:1083696025
Name:LEWIS, EDWARD S (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:S
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 1:11623 ANGUS RD STE 15
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4041
Mailing Address - Country:US
Mailing Address - Phone:512-346-7170
Mailing Address - Fax:512-345-2699
Practice Address - Street 1:11623 ANGUS RD
Practice Address - Street 2:STE 15
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4041
Practice Address - Country:US
Practice Address - Phone:512-346-7170
Practice Address - Fax:512-345-2699
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3210207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD66804Medicare UPIN
TX8A7673Medicare PIN