Provider Demographics
NPI:1952516734
Name:LEWIS, RICHARD GORDON JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GORDON
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:2331A ROBIOUS STATION CIR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2124
Practice Address - Country:US
Practice Address - Phone:804-267-6009
Practice Address - Fax:804-267-6017
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012304712086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1952516734Medicaid
VAC05349OtherMC GROUP NUMBER
VAC05349OtherMC GROUP NUMBER
VA014949P49Medicare PIN
VA1952516734Medicare UPIN
VA00Y207R01Medicare PIN