Provider Demographics
NPI:1164514436
Name:LEWIS, JEREMY C (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:C
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-9046
Mailing Address - Country:US
Mailing Address - Phone:509-447-2441
Mailing Address - Fax:509-447-0456
Practice Address - Street 1:714 W PINE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156-9046
Practice Address - Country:US
Practice Address - Phone:509-447-2441
Practice Address - Fax:509-447-0456
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001708207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8319212Medicaid
WA8319212Medicaid
H38144Medicare UPIN