Provider Demographics
NPI:1154505519
Name:LEWIS, KENNETH SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:SCOTT
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:106 BOW STREET
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921
Mailing Address - Country:US
Mailing Address - Phone:410-392-7009
Mailing Address - Fax:410-620-1494
Practice Address - Street 1:106 BOW STREET
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921
Practice Address - Country:US
Practice Address - Phone:410-392-7009
Practice Address - Fax:410-620-1494
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0019043207R00000X
DEC1-0001534207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD460701500Medicaid