Provider Demographics
NPI:1801085576
Name:LEWIS, SCOTT ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ROBERT
Last Name:LEWIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19610 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-7472
Mailing Address - Country:US
Mailing Address - Phone:360-258-6234
Mailing Address - Fax:360-258-6235
Practice Address - Street 1:19610 SE 1ST ST
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-7472
Practice Address - Country:US
Practice Address - Phone:360-258-6234
Practice Address - Fax:360-258-6235
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3587152W00000X
OR2787ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U81021Medicare UPIN