Provider Demographics
NPI:1225623671
Name:LEWIS, BEVERLY J
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 S ALAFAYA TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8957
Mailing Address - Country:US
Mailing Address - Phone:407-203-3888
Mailing Address - Fax:
Practice Address - Street 1:1537 S ALAFAYA TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8957
Practice Address - Country:US
Practice Address - Phone:407-203-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2322733363LF0000X
FLAPRN11028652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN23227332021Medicaid