Provider Demographics
NPI:1659310191
Name:LEWIS, RICHARD J (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
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 1:3015 3RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-5418
Mailing Address - Country:US
Mailing Address - Phone:605-226-5500
Mailing Address - Fax:605-226-4601
Practice Address - Street 1:3015 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-5418
Practice Address - Country:US
Practice Address - Phone:605-226-5500
Practice Address - Fax:605-226-4601
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63368207V00000X
MT20182207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA293211408AMedicaid
NJE96976Medicare UPIN
GA293211408AMedicaid
NJ4582501Medicare ID - Type Unspecified