Provider Demographics
NPI:1396706487
Name:LEWIS, JACK BYRON (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:BYRON
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:252 MATLOCK RD STE 244
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4294
Mailing Address - Country:US
Mailing Address - Phone:817-784-8268
Mailing Address - Fax:817-477-8881
Practice Address - Street 1:252 MATLOCK RD STE 244
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4294
Practice Address - Country:US
Practice Address - Phone:817-784-8268
Practice Address - Fax:817-477-8881
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43653-020208800000X
ORMD28015208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology