Basic Information
| Provider Information | |||||||||
| NPI: | 1295979474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | JEREMY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 3920 ST FRANCIS WAY STE 220 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654285950 | ||||||||
| FaxNumber: | 7654285951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2009 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 5101017835 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 208800000X | 3622 | KY | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 02006859A | IN | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.