Provider Demographics
NPI:1255082095
Name:LEWIS, JAKE EVAN (MD)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:EVAN
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 1:1496 E SPRING GATE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6893
Mailing Address - Country:US
Mailing Address - Phone:208-573-7653
Mailing Address - Fax:
Practice Address - Street 1:1960 N OGDEN ST STE 110
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-3667
Practice Address - Country:US
Practice Address - Phone:303-812-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program