Provider Demographics
NPI:1568411858
Name:LEWIS, ROGER A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
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 1:603B W STATE AVE
Mailing Address - Street 2:
Mailing Address - City:TERRA ALTA
Mailing Address - State:WV
Mailing Address - Zip Code:26764-1223
Mailing Address - Country:US
Mailing Address - Phone:304-789-2457
Mailing Address - Fax:304-789-6812
Practice Address - Street 1:603B W STATE AVE
Practice Address - Street 2:
Practice Address - City:TERRA ALTA
Practice Address - State:WV
Practice Address - Zip Code:26764-1223
Practice Address - Country:US
Practice Address - Phone:304-789-2457
Practice Address - Fax:304-789-6812
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV12705207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVCM7276OtherMEDICARE RAILROAD
WV056529000Medicaid
WV056529000Medicaid
WVWV25830281Medicare PIN