Healthcare Provider Details

I. General information

NPI: 1053937995
Provider Name (Legal Business Name): IAN ZACHARY LEWIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 NE GLEN OAK AVE STE 401
PEORIA IL
61603
US

IV. Provider business mailing address

1240 E MONROE ST
MORTON IL
61550-2356
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-8123
  • Fax: 309-676-8455
Mailing address:
  • Phone: 734-301-8648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036180691
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036180691
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: