Healthcare Provider Details

I. General information

NPI: 1215964309
Provider Name (Legal Business Name): RANDAL JOHN LEWIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 08/02/2020
Certification Date: 08/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E 4500 S STE 410
MURRAY UT
84107-3993
US

IV. Provider business mailing address

1082 N 1000 W
AMERICAN FORK UT
84003-3897
US

V. Phone/Fax

Practice location:
  • Phone: 801-850-2800
  • Fax:
Mailing address:
  • Phone: 801-850-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number89-246
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6901924-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: