Provider Demographics
NPI:1699847731
Name:LEWIS, DARREN BLAINE (MD)
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:BLAINE
Last Name:LEWIS
Suffix:
Gender:M
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4015 MERCANTILE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2552
Practice Address - Country:US
Practice Address - Phone:503-216-1500
Practice Address - Fax:503-216-1515
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00784496OtherRR MEDICARE
OR218441Medicaid
ORP00784496OtherRR MEDICARE
ORR140650Medicare PIN