Provider Demographics
NPI:1114981966
Name:LEWIS, WALLACE E (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:E
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:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-1328
Mailing Address - Country:US
Mailing Address - Phone:804-435-8570
Mailing Address - Fax:804-435-8037
Practice Address - Street 1:18682 NORTHUMBERLAND HWY
Practice Address - Street 2:
Practice Address - City:REEDVILLE
Practice Address - State:VA
Practice Address - Zip Code:22539-3411
Practice Address - Country:US
Practice Address - Phone:804-453-4537
Practice Address - Fax:804-453-4713
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080133503OtherRAILROAD
VA1114981966Medicaid
VA1114981966Medicaid
VA080005506Medicare PIN