Provider Demographics
NPI:1154405322
Name:LEWIS, MICHELLE LEE (OD)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 ATWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-4841
Mailing Address - Country:US
Mailing Address - Phone:401-943-6000
Mailing Address - Fax:401-943-6017
Practice Address - Street 1:1404 ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-4841
Practice Address - Country:US
Practice Address - Phone:401-943-6000
Practice Address - Fax:401-943-6017
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00542152W00000X
MA4149152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIML78433Medicaid
RI001335901Medicare PIN