Healthcare Provider Details

I. General information

NPI: 1538203856
Provider Name (Legal Business Name): JOAN P LEWIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 11/05/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5065 CORRALES RD
CORRALES NM
87048-8629
US

IV. Provider business mailing address

PO BOX 2480
CORRALES NM
87048-2480
US

V. Phone/Fax

Practice location:
  • Phone: 505-404-8154
  • Fax: 505-919-7061
Mailing address:
  • Phone: 505-404-8154
  • Fax: 505-919-7061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code193200000X
TaxonomyMulti-Specialty Group
License Number94-300
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number94-300
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: