Provider Demographics
NPI:1528222775
Name:LEWIS, GIAVONNI MYSTIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:GIAVONNI
Middle Name:MYSTIQUE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 413035
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3035
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-585-3655
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0100
Practice Address - Country:US
Practice Address - Phone:801-581-8990
Practice Address - Fax:801-585-6005
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8365805-1205208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery