Provider Demographics
NPI:1649798133
Name:LEWIS, ROOSEVELT III (NP)
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:LEWIS
Suffix:III
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 VFW PKWY STE 301
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4344
Mailing Address - Country:US
Mailing Address - Phone:617-401-7441
Mailing Address - Fax:617-203-6651
Practice Address - Street 1:1208 VFW PKWY STE 301
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02132-4344
Practice Address - Country:US
Practice Address - Phone:617-401-7441
Practice Address - Fax:617-203-6651
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2313246163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse