Provider Demographics
NPI:1710073580
Name:LEWIS, ANGELA DAWN (DO)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:DAWN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 KENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169
Mailing Address - Country:US
Mailing Address - Phone:606-836-1954
Mailing Address - Fax:606-836-3878
Practice Address - Street 1:1021 KENWOOD DR
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169
Practice Address - Country:US
Practice Address - Phone:606-836-1954
Practice Address - Fax:606-836-3878
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY02545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64025455Medicaid
KY080127343OtherRAILROAD MEDICARE
1725001Medicare ID - Type Unspecified
G76343Medicare UPIN