Provider Demographics
NPI:1417510017
Name:LEWIS, TASHEONNA CHRISSANDRA (MD)
Entity Type:Individual
Prefix:
First Name:TASHEONNA
Middle Name:CHRISSANDRA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21891 RIDGEDALE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-1553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.145366207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program