=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376920553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CREIGHTON LEWIS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2015
-----------------------------------------------------
Last Update Date | 06/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 WEST FORT ST. #111R BOISE VAMC
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-220-6546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 WEST FORT ST. #111R BOISE VAMC
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-220-6546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 11682730-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------