Healthcare Provider Details

I. General information

NPI: 1134234297
Provider Name (Legal Business Name): JERRY MERMOD LEWIS III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8226 DOUGLAS AVE SUITE #805
DALLAS TX
75225-5943
US

IV. Provider business mailing address

4737 CROOKED LN
DALLAS TX
75229-4212
US

V. Phone/Fax

Practice location:
  • Phone: 214-373-6194
  • Fax: 214-373-3404
Mailing address:
  • Phone: 214-676-4207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberE8664
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: