Provider Demographics
NPI:1689613960
Name:LEWIS, MARK G (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
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:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6204
Practice Address - Street 1:1200 E MICHIGAN AVE
Practice Address - Street 2:SUITE 345
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912
Practice Address - Country:US
Practice Address - Phone:517-364-6210
Practice Address - Fax:517-364-2842
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000903A174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325730BMedicaid
IN735850IMedicare ID - Type Unspecified
IN100325730BMedicaid