Provider Demographics
NPI:1720138357
Name:LEW, MYRA JOY (OD)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:JOY
Last Name:LEW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 L ST
Mailing Address - Street 2:#A-1024
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-3340
Mailing Address - Country:US
Mailing Address - Phone:916-554-1090
Mailing Address - Fax:
Practice Address - Street 1:1689 ARDEN WAY
Practice Address - Street 2:ARDEN FAIR SHOPOING CENTER #1344
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4030
Practice Address - Country:US
Practice Address - Phone:916-922-5666
Practice Address - Fax:916-922-4373
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0119150Medicare ID - Type Unspecified
CAU93266Medicare UPIN