Provider Demographics
NPI:1215920640
Name:LEWIS, KATHRYN MARIE (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
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:PO BOX 6325
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77325-6325
Mailing Address - Country:US
Mailing Address - Phone:281-360-5400
Mailing Address - Fax:281-548-3513
Practice Address - Street 1:4920 N.E. STALLILNGS DRIVE
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961
Practice Address - Country:US
Practice Address - Phone:936-568-3493
Practice Address - Fax:281-548-3513
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH05642085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032010301Medicaid
E02190Medicare UPIN
8564J0Medicare PIN