Provider Demographics
NPI:1710906128
Name:LEWIS, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
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 1:1185 CORPORATE CENTER DR STE 175
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4889
Mailing Address - Country:US
Mailing Address - Phone:262-928-8400
Mailing Address - Fax:262-928-8484
Practice Address - Street 1:15450 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4241
Practice Address - Country:US
Practice Address - Phone:888-698-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69030207R00000X
AZ32022207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7551697OtherAETNA
AZ2Z6843OtherHEALTHNET
AZAZ0760272OtherBCBS
AZ7551697OtherAETNA
AZ2Z6843OtherHEALTHNET