Basic Information
| Provider Information | |||||||||
| NPI: | 1114970324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | KENT | ||||||||
| MiddleName: | TALMAGE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7060 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852467060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804442017 | ||||||||
| FaxNumber: | 4805457181 | ||||||||
| Practice Location | |||||||||
| Address1: | 3331 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805451100 | ||||||||
| FaxNumber: | 4805457181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3462 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1Z0862 | 01 | AZ | HEALTH NET AZ | OTHER | 482331001 | 05 | AZ | MEDICAID | AZ0891420 | 01 | AZ | BCBS | OTHER |