Healthcare Provider Details

I. General information

NPI: 1720091481
Provider Name (Legal Business Name): RAYMOND C LEWANDOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 E MAIN ST
WILLOW SPRINGS MO
65793-1518
US

IV. Provider business mailing address

3800 S NATIONAL AVE #540
SPRINGFIELD MO
65807-5209
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number114869
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: