Provider Demographics
NPI:1366559577
Name:LEWIS, SUE A (MD)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:A
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 1:17704 JEAN WAY
Mailing Address - Street 2:STE 105
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5497
Mailing Address - Country:US
Mailing Address - Phone:503-675-6776
Mailing Address - Fax:503-675-2372
Practice Address - Street 1:17704 JEAN WAY
Practice Address - Street 2:STE 105
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5497
Practice Address - Country:US
Practice Address - Phone:503-675-6776
Practice Address - Fax:503-675-2372
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD19554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR077128Medicaid
OR831437000OtherBCBS
OR117676Medicare ID - Type Unspecified
OR077128Medicaid