Provider Demographics
NPI:1336139518
Name:LEWIS, STEPHEN W (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:W
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 1:2611 GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3907
Mailing Address - Country:US
Mailing Address - Phone:318-631-2020
Mailing Address - Fax:318-621-3023
Practice Address - Street 1:2611 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3907
Practice Address - Country:US
Practice Address - Phone:318-631-2020
Practice Address - Fax:318-621-3023
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1012-018T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
48222B775Medicare ID - Type Unspecified
T19519Medicare UPIN