Provider Demographics
NPI:1760923726
Name:LEWIS, MARCUS
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E UNIVERSITY DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-8136
Mailing Address - Country:US
Mailing Address - Phone:602-369-3497
Mailing Address - Fax:480-921-4115
Practice Address - Street 1:1550 E UNIVERSITY DR
Practice Address - Street 2:SUITE G
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-8136
Practice Address - Country:US
Practice Address - Phone:602-369-3497
Practice Address - Fax:480-921-4115
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ81-5054569405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ81-5054569Medicaid