Provider Demographics
NPI:1467064832
Name:LEWIS, KENNETH ROBERT (NYCPS-3799)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:LEWIS
Suffix:
Gender:M
Credentials:NYCPS-3799
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N GOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-1185
Mailing Address - Country:US
Mailing Address - Phone:585-325-3145
Mailing Address - Fax:585-244-3999
Practice Address - Street 1:320 N GOODMAN ST STE 202320
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1185
Practice Address - Country:US
Practice Address - Phone:585-325-3145
Practice Address - Fax:585-244-3999
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P-3799175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist