Provider Demographics
NPI:1740336791
Name:LEWIS, MELISSA R (OD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:R
Last Name:LEWIS
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 1:28 ARNOLD MALL
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-2223
Mailing Address - Country:US
Mailing Address - Phone:636-282-2700
Mailing Address - Fax:636-282-3084
Practice Address - Street 1:28 ARNOLD MALL
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2223
Practice Address - Country:US
Practice Address - Phone:636-282-2700
Practice Address - Fax:636-282-3084
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMOTO3404152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA 1595008OtherMEDICARE ID
MOMA 1595008OtherMEDICARE ID
P00018300Medicare PIN