Provider Demographics
NPI:1104865872
Name:LEWIS, MARION STEWART (OD)
Entity Type:Individual
Prefix:DR
First Name:MARION
Middle Name:STEWART
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4876
Mailing Address - Country:US
Mailing Address - Phone:863-940-2091
Mailing Address - Fax:863-940-4764
Practice Address - Street 1:3615 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4876
Practice Address - Country:US
Practice Address - Phone:863-940-2091
Practice Address - Fax:863-940-4764
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078905400Medicaid
FL20368VMedicare ID - Type Unspecified
FL078905400Medicaid