Provider Demographics
NPI:1588192520
Name:LEWIS, MALLORY DIANE (DO)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:DIANE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:DIANE
Other - Last Name:STREIFFERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:3754 HIGHWAY 90 STE 300
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1098
Practice Address - Country:US
Practice Address - Phone:850-416-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17878207QS0010X, 207Q00000X, 207QS0010X
ALDO.2312207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine