Provider Demographics
NPI:1205987831
Name:LEWIS, MATTHEW THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
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 1:1705 CHRISTY DR
Mailing Address - Street 2:STE. 101
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5195
Mailing Address - Country:US
Mailing Address - Phone:573-635-0115
Mailing Address - Fax:573-635-0116
Practice Address - Street 1:1705 CHRISTY DR
Practice Address - Street 2:STE. 101
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5195
Practice Address - Country:US
Practice Address - Phone:573-635-0115
Practice Address - Fax:573-635-0116
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3P66174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206665812Medicaid
MOE82913Medicare UPIN
MO206665812Medicaid