Provider Demographics
NPI:1699741298
Name:LEWIS, JOHNATHAN W (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:W
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 MAGNOLIA RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71701-4146
Mailing Address - Country:US
Mailing Address - Phone:870-836-4709
Mailing Address - Fax:870-836-5837
Practice Address - Street 1:430 MAGNOLIA RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-4146
Practice Address - Country:US
Practice Address - Phone:870-836-5709
Practice Address - Fax:870-837-2842
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000252732102OtherUNITED HEALTH CARE
AR771003001OtherBREASTCARE
P00229512OtherRAILROAD MEDICARE
AR05030029800OtherQUALCHOICE
AR154567001Medicaid
7165646OtherAETNA
AR154567001Medicaid
5M877Medicare ID - Type Unspecified