Healthcare Provider Details

I. General information

NPI: 1356322507
Provider Name (Legal Business Name): MARK E. LEWIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 LIBERTY ST 310
MEADVILLE PA
16335-2566
US

IV. Provider business mailing address

1034 GROVE ST
MEADVILLE PA
16335-2945
US

V. Phone/Fax

Practice location:
  • Phone: 814-333-7030
  • Fax:
Mailing address:
  • Phone: 814-373-2923
  • Fax: 814-333-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS008626L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-006416
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: