Healthcare Provider Details

I. General information

NPI: 1295979474
Provider Name (Legal Business Name): LEWIS JEREMY JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

IV. Provider business mailing address

210 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-747-4332
  • Fax: 765-448-7689
Mailing address:
  • Phone: 765-747-4332
  • Fax: 765-448-7689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101017835
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number3622
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number02006859A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: