Provider Demographics
NPI:1881613974
Name:VICHINSKY, LEWIS M (DPM)
Entity type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:M
Last Name:VICHINSKY
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 1:245 STOCKSDALE DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1563
Mailing Address - Country:US
Mailing Address - Phone:937-642-9936
Mailing Address - Fax:937-642-5537
Practice Address - Street 1:245 STOCKSDALE DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1563
Practice Address - Country:US
Practice Address - Phone:937-642-9936
Practice Address - Fax:937-642-5537
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001774V213E00000X
LADPMPDD14R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2457934Medicaid
P00092942OtherRR MCR
OH2457934Medicaid
P00092942OtherRR MCR
061702747OtherTIN