Provider Demographics
NPI:1578892139
Name:LEWIS, DANIEL J
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
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 1:223 SILVER RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5831
Mailing Address - Country:US
Mailing Address - Phone:207-942-4186
Mailing Address - Fax:
Practice Address - Street 1:223 SILVER RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5831
Practice Address - Country:US
Practice Address - Phone:207-942-4186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 3512373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME202310000Medicaid