Provider Demographics
NPI:1679860142
Name:LEWIS, NICOLE L (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 CAMDEN AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-2847
Mailing Address - Country:US
Mailing Address - Phone:408-997-9155
Mailing Address - Fax:
Practice Address - Street 1:6475 CAMDEN AVE STE 105
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120
Practice Address - Country:US
Practice Address - Phone:408-997-9155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC159091207Q00000X
MI4301098534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine