Provider Demographics
NPI:1841381035
Name:LEWIS, SANDRA J (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
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 1:100 WOODSCAPE WAY
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9322
Mailing Address - Country:US
Mailing Address - Phone:304-760-0447
Mailing Address - Fax:
Practice Address - Street 1:4004 MACCORKLE AVE SE
Practice Address - Street 2:SUITE 1A
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1672
Practice Address - Country:US
Practice Address - Phone:304-926-0172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0054964000Medicaid
WV0829231Medicare ID - Type Unspecified
WV0054964000Medicaid