Provider Demographics
NPI:1861453144
Name:LEWIS, IVOR F (MD)
Entity Type:Individual
Prefix:DR
First Name:IVOR
Middle Name:F
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:701 W OAK ST
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931
Practice Address - Country:US
Practice Address - Phone:570-874-4100
Practice Address - Fax:570-874-4182
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD019501E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000615820Medicaid
B35380Medicare UPIN
PA000615820Medicaid