Healthcare Provider Details

I. General information

NPI: 1275789067
Provider Name (Legal Business Name): EDWARD S LEWIS, MDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11623 ANGUS RD STE 15
AUSTIN TX
78759-4041
US

IV. Provider business mailing address

11623 ANGUS RD STE 15
AUSTIN TX
78759-4041
US

V. Phone/Fax

Practice location:
  • Phone: 512-346-7170
  • Fax: 512-345-2699
Mailing address:
  • Phone: 512-346-7170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberF3210
License Number StateTX

VIII. Authorized Official

Name: EDWARD S LEWIS
Title or Position: OWNER
Credential: MD
Phone: 512-346-7170