Healthcare Provider Details

I. General information

NPI: 1760434138
Provider Name (Legal Business Name): ANGELA RICELLE LEWIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 01/25/2020
Certification Date: 01/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 SILVER LAKE CT
SAVOY IL
61874-7449
US

IV. Provider business mailing address

606 SILVER LAKE CT
SAVOY IL
61874-7449
US

V. Phone/Fax

Practice location:
  • Phone: 225-235-0151
  • Fax:
Mailing address:
  • Phone: 225-235-0151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number036.133963
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number15245
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number020628
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: