Healthcare Provider Details

I. General information

NPI: 1083696025
Provider Name (Legal Business Name): EDWARD S LEWIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
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: 512-345-2699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberF3210
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: