Healthcare Provider Details

I. General information

NPI: 1255082095
Provider Name (Legal Business Name): JAKE EVAN LEWIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 N OGDEN ST STE 110
DENVER CO
80218-3667
US

IV. Provider business mailing address

1496 E SPRING GATE DR
HOLLADAY UT
84117-6893
US

V. Phone/Fax

Practice location:
  • Phone: 303-812-6850
  • Fax:
Mailing address:
  • Phone: 208-573-7653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: