Provider Demographics
NPI:1194928994
Name:LEWIS, ELENA JEAN (MD)
Entity type:Individual
Prefix:DR
First Name:ELENA
Middle Name:JEAN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 W MILHAM AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2239
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:1324 W MILHAM AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-2239
Practice Address - Country:US
Practice Address - Phone:269-342-0196
Practice Address - Fax:269-342-0532
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085524208000000X
MIEL085524207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700C910950OtherBCBSM
MI1194928994Medicaid