Provider Demographics
NPI:1437198645
Name:LEWIS, JONATHAN ADAM (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ADAM
Last Name:LEWIS
Suffix:
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 950138
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0138
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:610 E BRANNON RD
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-6066
Practice Address - Country:US
Practice Address - Phone:859-260-5540
Practice Address - Fax:859-260-4399
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39542207Q00000X
KY40193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437198645Medicaid
TN3330555Medicaid
TN33305532Medicare PIN
VAC09112Medicare UPIN
VA1437198645Medicaid
TN3330555Medicaid
TN3709285Medicare UPIN