Provider Demographics
NPI:1598719825
Name:GRODA-LEWIS, MARY LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:GRODA-LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GRODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1322 3RD ST SE
Mailing Address - Street 2:STE 240
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3771
Mailing Address - Country:US
Mailing Address - Phone:253-697-5757
Mailing Address - Fax:
Practice Address - Street 1:1322 3RD ST SE
Practice Address - Street 2:STE 240
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3771
Practice Address - Country:US
Practice Address - Phone:253-697-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA38085207Q00000X
WAMD00038716207Q00000X, 208D00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00677919OtherRR MEDICARE
IAP00677919OtherRR MEDICARE