Provider Demographics
NPI:1255983177
Name:LEWIS, JEHDEIAH B (MD,REV, PHD)
Entity type:Individual
Prefix:DR
First Name:JEHDEIAH
Middle Name:B
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD,REV, PHD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:B
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1542 WILHELMINA RISE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-7303
Mailing Address - Country:US
Mailing Address - Phone:808-371-7902
Mailing Address - Fax:808-278-5654
Practice Address - Street 1:1542 WILHELMINA RISE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-7303
Practice Address - Country:US
Practice Address - Phone:808-371-7902
Practice Address - Fax:808-278-5654
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3759872207R00000X, 208VP0000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIBL9500491OtherDEA NUMBER