Provider Demographics
NPI:1114922622
Name:TONDO, LEWIS JOHN (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:JOHN
Last Name:TONDO
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 1:510 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROUTMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28166-9529
Mailing Address - Country:US
Mailing Address - Phone:704-528-3721
Mailing Address - Fax:
Practice Address - Street 1:510 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TROUTMAN
Practice Address - State:NC
Practice Address - Zip Code:28166-9529
Practice Address - Country:US
Practice Address - Phone:704-528-3721
Practice Address - Fax:704-528-5273
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01075207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8983635Medicaid
NC8983635Medicaid
NC60346FMedicare UPIN