Provider Demographics
NPI:1578978805
Name:LEWIS, VANCE PERRY (OD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:PERRY
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S 63RD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1619
Mailing Address - Country:US
Mailing Address - Phone:480-641-3937
Mailing Address - Fax:480-924-5094
Practice Address - Street 1:220 S 63RD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1619
Practice Address - Country:US
Practice Address - Phone:480-641-3937
Practice Address - Fax:303-800-2078
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1989152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ923758Medicaid
AZZ167524Medicare PIN
AZZ162079Medicare PIN
AZZ162076Medicare PIN
AZZ162074Medicare PIN
AZZ162075Medicare PIN
AZZ167526Medicare PIN
AZZ167525Medicare PIN
AZZ162077Medicare PIN
AZZ162078Medicare PIN
AZZ167523Medicare PIN
AZZ167521Medicare PIN