Provider Demographics
NPI:1295979474
Name:JOHNSON, LEWIS JEREMY (DO)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:JEREMY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-747-4332
Mailing Address - Fax:765-448-7689
Practice Address - Street 1:210 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3988
Practice Address - Country:US
Practice Address - Phone:765-747-4332
Practice Address - Fax:765-448-7689
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017835208600000X
KY3622208800000X
IN02006859A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300066454Medicaid
IN1102384432OtherANTHEM PTAN