Healthcare Provider Details

I. General information

NPI: 1467454702
Provider Name (Legal Business Name): YURI LEWICKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 N TURQUOISE DR SUITE 200
FLAGSTAFF AZ
86001-1398
US

IV. Provider business mailing address

1485 N TURQUOISE DRIVE
FLAGSTAFF AZ
86001
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-7757
  • Fax: 928-774-7767
Mailing address:
  • Phone: 928-774-4460
  • Fax: 928-226-3071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number33479
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: