=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174626402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW DAVID LEWIS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20817 HIGHWAY 266
-----------------------------------------------------
City | ROCKY FORD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-254-3532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 481
-----------------------------------------------------
City | LA JUNTA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-469-9220
-----------------------------------------------------
Fax | 719-384-6511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 33928
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------