Provider Demographics
NPI:1215066766
Name:LEWIS, ENID D (RD)
Entity type:Individual
Prefix:
First Name:ENID
Middle Name:D
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RD
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5654
Practice Address - Street 1:1010 SPRUCE ST
Practice Address - Street 2:ESPANOLA HOSPITAL
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2724
Practice Address - Country:US
Practice Address - Phone:505-753-7111
Practice Address - Fax:505-753-4438
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM525207Q00000X, 133V00000X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
341324702Medicare PIN
N/AMedicare UPIN