Provider Demographics
NPI:1790770386
Name:LEWIS, MARY LOU (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOU
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 1:7026 VALLEY BROOK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-9460
Mailing Address - Country:US
Mailing Address - Phone:304-984-3013
Mailing Address - Fax:
Practice Address - Street 1:501 MORRIS STREET
Practice Address - Street 2:CAMC
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-388-7191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV9415204F00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVAL1382299OtherDEA NUMBER