Provider Demographics
NPI:1619443033
Name:LEWIS, JOHN O III
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:O
Last Name:LEWIS
Suffix:III
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 1:6342 28TH ST APT 16
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2723
Mailing Address - Country:US
Mailing Address - Phone:773-712-7928
Mailing Address - Fax:
Practice Address - Street 1:6342 28TH ST APT 16
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2723
Practice Address - Country:US
Practice Address - Phone:773-712-7928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-12-12
Deactivation Date:2018-11-25
Deactivation Code:
Reactivation Date:2018-12-12
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)