Provider Demographics
NPI:1215964309
Name:LEWIS, RANDAL JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:JOHN
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 1:1082 N 1000 W
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3897
Mailing Address - Country:US
Mailing Address - Phone:801-850-2800
Mailing Address - Fax:
Practice Address - Street 1:310 E 4500 S STE 410
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3993
Practice Address - Country:US
Practice Address - Phone:801-850-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM89-246173000000X
UT6901924-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME2139Medicaid
NM002400968OtherCIGNA PROVIDER NUMBER
NM4468903OtherAETNA PROVIDER NUMBER
NM4468903OtherAETNA PROVIDER NUMBER
NME2139Medicaid
NM4182OtherLOVELACE PROVIDER NUMBER
NM002400968OtherCIGNA PROVIDER NUMBER