Provider Demographics
NPI: | 1437122108 |
---|---|
Name: | LEWIS, THEODORE H JR (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | THEODORE |
Middle Name: | H |
Last Name: | LEWIS |
Suffix: | JR |
Gender: | M |
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: | PO BOX 967 |
Mailing Address - Street 2: | |
Mailing Address - City: | FLAGSTAFF |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 86002-0967 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 928-773-0003 |
Mailing Address - Fax: | 928-773-1170 |
Practice Address - Street 1: | 1200 N BEAVER ST |
Practice Address - Street 2: | |
Practice Address - City: | FLAGSTAFF |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 86002 |
Practice Address - Country: | US |
Practice Address - Phone: | 928-773-0003 |
Practice Address - Fax: | 928-773-1170 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-02-10 |
Last Update Date: | 2013-05-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 23470 | 207RP1001X, 207RC0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 312570 | Medicaid | |
112857 | Medicare PIN | ||
AZ | 312570 | Medicaid | |
E42954 | Medicare UPIN |