Provider Demographics
NPI:1538657689
Name:LEWIS, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 MONTAGUE ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-2875
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1751 STANTON TER SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2823
Practice Address - Country:US
Practice Address - Phone:202-907-5698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant