=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053458539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. MARION S. LEWIS & ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 02/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5535 KINGS MONT DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-3280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-648-4770
-----------------------------------------------------
Fax | 888-873-4425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5535 KINGS MONT DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-3280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-648-4770
-----------------------------------------------------
Fax | 888-873-4425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARION STEWART LEWIS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 863-648-4770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC1235
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------