Healthcare Provider Details

I. General information

NPI: 1114981966
Provider Name (Legal Business Name): WALLACE E LEWIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18682 NORTHUMBERLAND HWY
REEDVILLE VA
22539-3411
US

IV. Provider business mailing address

PO BOX 1328
KILMARNOCK VA
22482-1328
US

V. Phone/Fax

Practice location:
  • Phone: 804-453-4537
  • Fax: 804-453-4713
Mailing address:
  • Phone: 804-435-8570
  • Fax: 804-435-8037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101028388
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: