Healthcare Provider Details

I. General information

NPI: 1174500789
Provider Name (Legal Business Name): ALAN K. LEWIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 GRAND AVE
CARTHAGE MO
64836
US

IV. Provider business mailing address

6748 RACCOON RD
GRANBY MO
64844-7111
US

V. Phone/Fax

Practice location:
  • Phone: 417-358-1203
  • Fax: 417-358-3649
Mailing address:
  • Phone: 417-389-0665
  • Fax: 417-358-3649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02723
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: