Basic Information
| Provider Information | |||||||||
| NPI: | 1740286590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7045 LIGHTHOUSE WAY | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198736836 | ||||||||
| FaxNumber: | 4198736837 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912051 | ||||||||
| FaxNumber: | 4194796952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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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 | 35051429 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6895 | 01 | MI | HPM | OTHER | 000000030933 | 01 | OH | ANTHEM WWK | OTHER | 344428256080 | 01 | OH | CARESOURCES | OTHER | 4091 | 01 | OH | NATIONWIDE | OTHER | 4002483 | 01 | OH | AETNA | OTHER | 4002483 | 01 | MI | PPOM | OTHER | 142072 | 01 | OH | CARE CHOICES | OTHER | 142072 | 01 | OH | PRIORITY | OTHER | 000000296936 | 01 | OH | ANTHEM CHS | OTHER | 01-04068 | 01 | OH | UNITED | OTHER | 0877047 | 05 | OH | MEDICAID | 1078435002 | 01 | OH | CIGNA | OTHER | 344428256 | 01 | MI | PHCS | OTHER |