Provider Demographics
NPI:1770581910
Name:LEWIS, MARK THOMAS (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 TALBOT RD S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6238
Mailing Address - Country:US
Mailing Address - Phone:425-277-3668
Mailing Address - Fax:425-277-0732
Practice Address - Street 1:4300 TALBOT RD S
Practice Address - Street 2:SUITE 102
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6238
Practice Address - Country:US
Practice Address - Phone:425-277-3668
Practice Address - Fax:425-277-0732
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7110729Medicaid
WA156352OtherDEPT OF L&I NUMBER
WA156352OtherDEPT OF L&I NUMBER
WA7110729Medicaid