Provider Demographics
NPI:1093935801
Name:LEWIS PODIATRY GROUP PA
Entity Type:Organization
Organization Name:LEWIS PODIATRY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-263-7042
Mailing Address - Street 1:504 N CARRIER PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-5428
Mailing Address - Country:US
Mailing Address - Phone:973-263-7042
Mailing Address - Fax:972-263-7046
Practice Address - Street 1:504 N CARRIER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5428
Practice Address - Country:US
Practice Address - Phone:973-263-7042
Practice Address - Fax:972-263-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1574213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180094801Medicaid
TX0006NHOtherBCBS
TX5557490001Medicare NSC
TX00W066Medicare UPIN