Provider Demographics
NPI:1407819493
Name:LEWIS, VINCENT JEROME (DO)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:JEROME
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 1:2560 RIVER PARK PLZ
Mailing Address - Street 2:STE 330
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-3948
Mailing Address - Country:US
Mailing Address - Phone:817-377-8300
Mailing Address - Fax:817-377-8302
Practice Address - Street 1:2560 RIVER PARK PLZ
Practice Address - Street 2:STE 330
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-3948
Practice Address - Country:US
Practice Address - Phone:817-377-8300
Practice Address - Fax:817-377-8302
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9595207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144847401Medicaid
TX144847402Medicaid
TX144847401Medicaid
TX8F21614Medicare PIN
TX144847402Medicaid