Provider Demographics
NPI:1992381693
Name:LEWIS, MICHAEL JR (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4927 WALNUT GROVE DR
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065-8600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:835 E 18TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1024
Practice Address - Country:US
Practice Address - Phone:303-825-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0073167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program