Provider Demographics
NPI:1427561331
Name:LEWIS, DARYLE
Entity Type:Individual
Prefix:
First Name:DARYLE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8610 S MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620
Mailing Address - Country:US
Mailing Address - Phone:773-992-6851
Mailing Address - Fax:
Practice Address - Street 1:8610 S MORGAN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-3248
Practice Address - Country:US
Practice Address - Phone:773-992-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL26337Medicaid