Provider Demographics
NPI:1982709341
Name:LEWIS, JOHN BRAXTON (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRAXTON
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 1:1360 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9066
Mailing Address - Country:US
Mailing Address - Phone:941-480-2135
Mailing Address - Fax:941-484-2200
Practice Address - Street 1:1236 JACARANDA BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292
Practice Address - Country:US
Practice Address - Phone:941-496-4444
Practice Address - Fax:941-496-4223
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1163152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078516400Medicaid
FL078516400Medicaid
19675Medicare ID - Type Unspecified