Provider Demographics
NPI:1255324299
Name:LEWIS, SCOTT RYAN (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RYAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13150 W PERSIMMON LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1986
Mailing Address - Country:US
Mailing Address - Phone:208-939-0510
Mailing Address - Fax:208-939-0522
Practice Address - Street 1:2051 S COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2815
Practice Address - Country:US
Practice Address - Phone:208-672-1200
Practice Address - Fax:208-939-0522
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5948980-9934152W00000X
IDODP 100160152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist