Provider Demographics
NPI:1063414670
Name:LEWIS, BRADLEY JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JONATHAN
Last Name:LEWIS
Suffix:
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 1:1147 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-4056
Mailing Address - Country:US
Mailing Address - Phone:740-687-9173
Mailing Address - Fax:740-689-3740
Practice Address - Street 1:1147 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-4056
Practice Address - Country:US
Practice Address - Phone:740-687-9173
Practice Address - Fax:740-689-3740
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35056043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0697929Medicaid
OH0608654Medicare PIN
E61412Medicare UPIN
OH0697929Medicaid