Provider Demographics
NPI:1356322507
Name:LEWIS, MARK E (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
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 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-2923
Mailing Address - Fax:814-333-5640
Practice Address - Street 1:765 LIBERTY ST
Practice Address - Street 2:310
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2566
Practice Address - Country:US
Practice Address - Phone:814-333-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008626L207Q00000X
OH34-006416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0313539Medicaid
OH0313539Medicaid
692225Medicare ID - Type Unspecified