Provider Demographics
NPI:1811007925
Name:LEWIS, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:2197 BLACKBERRY DR
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134
Mailing Address - Country:US
Mailing Address - Phone:630-232-7600
Mailing Address - Fax:630-232-7941
Practice Address - Street 1:2197 BLACKBERRY DR
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-232-7600
Practice Address - Fax:630-232-7941
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036074413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C41239Medicare UPIN