Provider Demographics
NPI:1447584636
Name:LEWIS, RYAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:D
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 1:717 W MYSTIC CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4691
Mailing Address - Country:US
Mailing Address - Phone:801-618-5774
Mailing Address - Fax:
Practice Address - Street 1:717 W MYSTIC CREEK WAY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4691
Practice Address - Country:US
Practice Address - Phone:801-618-5774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7036277-1205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice