Provider Demographics
NPI:1629037239
Name:LEWIS, DOUGLAS DALZIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:DALZIEL
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 STRUTHERS LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:OH
Mailing Address - Zip Code:44405-1973
Mailing Address - Country:US
Mailing Address - Phone:330-750-1333
Mailing Address - Fax:330-750-0203
Practice Address - Street 1:315 STRUTHERS LIBERTY RD
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:OH
Practice Address - Zip Code:44405-1949
Practice Address - Country:US
Practice Address - Phone:330-750-1333
Practice Address - Fax:330-750-0203
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005881207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2022528Medicaid
OH2022528Medicaid