Provider Demographics
NPI:1760434138
Name:LEWIS, ANGELA RICELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:RICELLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 SILVER LAKE CT
Mailing Address - Street 2:
Mailing Address - City:SAVOY
Mailing Address - State:IL
Mailing Address - Zip Code:61874-7449
Mailing Address - Country:US
Mailing Address - Phone:225-235-0151
Mailing Address - Fax:
Practice Address - Street 1:606 SILVER LAKE CT
Practice Address - Street 2:
Practice Address - City:SAVOY
Practice Address - State:IL
Practice Address - Zip Code:61874-7449
Practice Address - Country:US
Practice Address - Phone:225-235-0151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.133963207WX0109X
AL15245207WX0109X
LA020628207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1112160Medicaid
LA4491110001Medicare NSC
LAF46969Medicare UPIN
LA4EO22Medicare ID - Type Unspecified