Provider Demographics
NPI:1184653818
Name:LEWIS, STEPHEN CHARLES (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CHARLES
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:1901 W PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119
Practice Address - Country:US
Practice Address - Phone:801-886-2020
Practice Address - Fax:801-954-0054
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1108139934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87017934007001OtherBC/BS
UT87017934024001OtherBC/BS
UT999000797009Medicaid
UT000009841OtherMEDICARE STORE #13 PTAN
UT000004481OtherMEDICARE STORE #5 PTAN
UT87017934007001OtherBC/BS
UT999000797009Medicaid
000009656Medicare ID - Type Unspecified
UT000004481OtherMEDICARE STORE #5 PTAN
T78160Medicare UPIN
UT0618950011Medicare NSC
UT000062787Medicare PIN