Provider Demographics
NPI:1821050329
Name:LEWIS, MICHAEL R (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 1:11401 TUNNEL HILL WAY
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7229
Mailing Address - Country:US
Mailing Address - Phone:916-631-8977
Mailing Address - Fax:
Practice Address - Street 1:9574 MICRON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2622
Practice Address - Country:US
Practice Address - Phone:916-361-2717
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist