Provider Demographics
NPI:1821632316
Name:LEWIS, DEREK J
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
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 1:2415 LATIMER RD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-8015
Mailing Address - Country:US
Mailing Address - Phone:615-430-5079
Mailing Address - Fax:
Practice Address - Street 1:2415 LATIMER RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-8015
Practice Address - Country:US
Practice Address - Phone:615-430-5079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007444225100000X
COPTL0016326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist