Provider Demographics
NPI:1265403497
Name:LEWIS, ADOLPHUS RAY (DO)
Entity type:Individual
Prefix:DR
First Name:ADOLPHUS
Middle Name:RAY
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:A.
Other - Middle Name:RAY
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:4732 E LANCASTER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-3836
Mailing Address - Country:US
Mailing Address - Phone:817-534-1010
Mailing Address - Fax:817-413-0300
Practice Address - Street 1:4732 E LANCASTER AVE STE A
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3836
Practice Address - Country:US
Practice Address - Phone:817-534-1010
Practice Address - Fax:817-413-0300
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CG231OtherBLUE CROSS BLUE SHIELD
TXP00864759OtherPALMETTO GBA RAILROAD MEDICARE
TX1215196-07Medicaid
TXTXB105776Medicare PIN
TXP00864759OtherPALMETTO GBA RAILROAD MEDICARE
TXA67333Medicare UPIN
TXTXB105776Medicare PIN