Provider Demographics
NPI:1265842611
Name:LEWIS, JACOB I (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:I
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 1:465 N PARK DR
Mailing Address - Street 2:APT 2103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-0008
Mailing Address - Country:US
Mailing Address - Phone:931-703-0303
Mailing Address - Fax:
Practice Address - Street 1:680 N LAKE SHORE DR STE 1000
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-8709
Practice Address - Country:US
Practice Address - Phone:312-926-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1249132085R0202X
IL036.1482582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology