Healthcare Provider Details

I. General information

NPI: 1265047187
Provider Name (Legal Business Name): JOHNATHAN LEWIS MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MAGNOLIA RD
CAMDEN AR
71701-4146
US

IV. Provider business mailing address

430 MAGNOLIA RD
CAMDEN AR
71701-4146
US

V. Phone/Fax

Practice location:
  • Phone: 870-836-5709
  • Fax: 870-836-5837
Mailing address:
  • Phone: 870-836-5709
  • Fax: 870-837-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHNATHAN LEWIS
Title or Position: OWNER
Credential: MD
Phone: 870-836-5709