Provider Demographics
NPI:1801142351
Name:LEWIS, JEFFREY (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:2221 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2375
Mailing Address - Country:US
Mailing Address - Phone:309-938-4949
Mailing Address - Fax:312-327-7621
Practice Address - Street 1:507 W TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1248
Practice Address - Country:US
Practice Address - Phone:217-531-5393
Practice Address - Fax:312-327-7621
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist