Healthcare Provider Details

I. General information

NPI: 1508153602
Provider Name (Legal Business Name): KERRY R. LEWIS M.D. LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2011
Last Update Date: 07/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10560 MAIN ST SUITE 210
FAIRFAX VA
22030-7182
US

IV. Provider business mailing address

10560 MAIN ST SUITE 210
FAIRFAX VA
22030-7182
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-3613
  • Fax:
Mailing address:
  • Phone: 703-273-3613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101028949
License Number StateVA

VIII. Authorized Official

Name: DR. KERRY RANDALL LEWIS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 703-273-3613