Provider Demographics
NPI:1093896342
Name:LEWIS, HOLLY (MD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-4157
Mailing Address - Fax:303-776-3109
Practice Address - Street 1:2101 KEN PRATT BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6567
Practice Address - Country:US
Practice Address - Phone:303-776-1532
Practice Address - Fax:303-776-3109
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0036981207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04005930Medicaid
G82907Medicare UPIN
CO04005930Medicaid