Provider Demographics
NPI:1114906054
Name:LEWIS, KEITH M (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:M
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 1:2559 WIGWAM PARKWAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-6230
Mailing Address - Country:US
Mailing Address - Phone:702-985-6044
Mailing Address - Fax:702-897-2896
Practice Address - Street 1:2559 WIGWAM PARKWAY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-6230
Practice Address - Country:US
Practice Address - Phone:702-982-3659
Practice Address - Fax:702-549-0377
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV72052085R0202X
CAG764992085R0202X
AZ249272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G76499Medicare UPIN
NV30WCHFV03Medicare ID - Type Unspecified