Provider Demographics
NPI:1245274505
Name:LEWIS, TODD C (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:C
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 1:3550 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 302
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4267
Mailing Address - Country:US
Mailing Address - Phone:904-733-4444
Mailing Address - Fax:904-733-5377
Practice Address - Street 1:300 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 1006
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3707
Practice Address - Country:US
Practice Address - Phone:904-794-7050
Practice Address - Fax:904-794-7135
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236867207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406745200Medicaid
MDKR65K445Medicare ID - Type Unspecified
DCG00773Medicare PIN
VAC06380Medicare PIN
MD406745200Medicaid
VAC09878Medicare PIN
MDH69083Medicare UPIN