Provider Demographics
NPI:1093714230
Name:LEWIS, FRED H (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:H
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 1:535 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1500
Mailing Address - Country:US
Mailing Address - Phone:716-372-0141
Mailing Address - Fax:716-376-2451
Practice Address - Street 1:535 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1500
Practice Address - Country:US
Practice Address - Phone:716-372-0141
Practice Address - Fax:716-376-2451
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131715207K00000X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00010264202OtherUNIVERA
NY00762327Medicaid
0206516OtherIHA
000500015002OtherBC/BS
040426004096OtherFIDELIS
000500015002OtherBC/BS
NYS33741Medicare ID - Type Unspecified
CC4156Medicare PIN
00010264202OtherUNIVERA