Provider Demographics
NPI:1770736803
Name:LEWCZYK, JEFFREY SCOTT (COTA)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:LEWCZYK
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:MR
Other - First Name:JEFFREY
Other - Middle Name:SCOTT
Other - Last Name:LEWCZYK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:6808 IVANHOE CT
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3062
Mailing Address - Country:US
Mailing Address - Phone:757-483-2630
Mailing Address - Fax:
Practice Address - Street 1:6808 IVANHOE CT
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3062
Practice Address - Country:US
Practice Address - Phone:757-483-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA978721174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist