Provider Demographics
NPI:1376735415
Name:LEWIS, SAMUEL GRADY (RTR,RPA,RA,CBRPA)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:GRADY
Last Name:LEWIS
Suffix:
Gender:M
Credentials:RTR,RPA,RA,CBRPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2001
Mailing Address - Country:US
Mailing Address - Phone:580-765-9588
Mailing Address - Fax:580-762-1367
Practice Address - Street 1:308 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2001
Practice Address - Country:US
Practice Address - Phone:580-765-9588
Practice Address - Fax:580-762-1367
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography