Provider Demographics
NPI:1134186729
Name:LEWIS, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37OO WASHINGTON STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8249
Mailing Address - Country:US
Mailing Address - Phone:954-983-6307
Mailing Address - Fax:954-983-5809
Practice Address - Street 1:37OO WASHINGTON STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8249
Practice Address - Country:US
Practice Address - Phone:954-983-6307
Practice Address - Fax:954-983-5809
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61959174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370555200Medicaid
FLE85045Medicare UPIN
FL370555200Medicaid