Provider Demographics
NPI:1760876510
Name:LEWIS, BRYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10338 BRISTOW CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-2201
Mailing Address - Country:US
Mailing Address - Phone:703-392-1010
Mailing Address - Fax:703-392-4975
Practice Address - Street 1:10338 BRISTOW CENTER DR
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-2201
Practice Address - Country:US
Practice Address - Phone:703-392-1010
Practice Address - Fax:703-392-4975
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008257152W00000X
VA0618002484152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist