Provider Demographics
NPI:1487653218
Name:LEWIS, DAVID P (MD PC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 SOUTH MEDICAL DR
Mailing Address - Street 2:SUITE G3
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3077
Mailing Address - Country:US
Mailing Address - Phone:435-734-2097
Mailing Address - Fax:435-734-0532
Practice Address - Street 1:990 SOUTH MEDICAL DR
Practice Address - Street 2:SUITE G3
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3077
Practice Address - Country:US
Practice Address - Phone:435-734-2097
Practice Address - Fax:435-734-0532
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171336-1205152W00000X
UT1713361205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003026200Medicaid
UT000002463Medicare PIN
UTD07539Medicare UPIN
UT000055400Medicare PIN