Provider Demographics
NPI:1255385779
Name:LEWIS-BOARDMAN, MARY BETH (MD)
Entity type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:
Last Name:LEWIS-BOARDMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16921 FLORENCE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MONTVERDE
Mailing Address - State:FL
Mailing Address - Zip Code:34756-3423
Mailing Address - Country:US
Mailing Address - Phone:352-348-3008
Mailing Address - Fax:
Practice Address - Street 1:305 S CHILDS ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5922
Practice Address - Country:US
Practice Address - Phone:352-348-3008
Practice Address - Fax:352-432-1479
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93877207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBL7810965OtherDEA NUMBER
FLBL7810965OtherDEA NUMBER
FLH78028Medicare UPIN