Provider Demographics
NPI:1689913188
Name:LEWIS, GARY WILLIAM (PT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:WILLIAM
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 VANDERFORD RD W
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5900
Mailing Address - Country:US
Mailing Address - Phone:904-269-2812
Mailing Address - Fax:
Practice Address - Street 1:1215 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4631
Practice Address - Country:US
Practice Address - Phone:904-269-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 1839225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist