Provider Demographics
NPI:1801856976
Name:LEWIS, TODD J (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:J
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 1:2230 N UNIVERSITY PKWY
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1594
Mailing Address - Country:US
Mailing Address - Phone:801-373-4550
Mailing Address - Fax:801-373-8634
Practice Address - Street 1:2230 N UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1509
Practice Address - Country:US
Practice Address - Phone:801-373-4550
Practice Address - Fax:801-373-8634
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT374753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU75123Medicare UPIN
UT00055756Medicare ID - Type UnspecifiedMEDICARE ID NUMBER