Healthcare Provider Details

I. General information

NPI: 1295779734
Provider Name (Legal Business Name): TODD JAY LEWIS M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 NW PROFESSIONAL DR STE 100
CORVALLIS OR
97330-3887
US

IV. Provider business mailing address

2211 NW PROFESSIONAL DR STE 100
CORVALLIS OR
97330-3887
US

V. Phone/Fax

Practice location:
  • Phone: 541-757-7463
  • Fax: 541-757-7465
Mailing address:
  • Phone: 541-757-7463
  • Fax: 541-757-7465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD13887
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: