MEDICARE: JERRY MERMOD LEWIS III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	E8664	TX

General Provider Information

NPI Number	:	1134234297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY MERMOD LEWIS III M.D.

Provider Business Mailing Address
First Line	:	4737 CROOKED LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75229-4212
Country	:	US
Telephone Number	:	214-676-4207
Fax Number	:

Provider Business Practice Location Address
First Line	:	8226 DOUGLAS AVE
Second Line	:	SUITE #805
City	:	DALLAS
State	:	TX
Zip	:	75225-5943
Country	:	US
Telephone Number	:	214-373-6194
Fax Number	:	214-373-3404

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/08/2007

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