Basic Information
Provider Information | |||||||||
NPI: | 1710964804 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEWIS | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 455 SHERMAN ST | ||||||||
Address2: | STE 510 | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802034400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033776825 | ||||||||
FaxNumber: | 3037800787 | ||||||||
Practice Location | |||||||||
Address1: | 455 SHERMAN | ||||||||
Address2: | SUITE 510 | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802034405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033776825 | ||||||||
FaxNumber: | 3037800787 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2005 | ||||||||
LastUpdateDate: | 04/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 32576 | CO | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP3000X | 32576 | CO | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
ID | Type | State | Issuer | Description | 112896500 | 05 | WY |   | MEDICAID | 7708070 | 05 | SD |   | MEDICAID | 01325760 | 05 | CO |   | MEDICAID | 100271490A | 05 | KS |   | MEDICAID | 3506685 | 05 | MT |   | MEDICAID | 805647500 | 05 | ID |   | MEDICAID | 058705701 | 05 | TX |   | MEDICAID | 84113438513 | 05 | NE |   | MEDICAID | L4892 | 05 | NM |   | MEDICAID |