=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992033021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERI M LEWIS MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2009
-----------------------------------------------------
Last Update Date | 12/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7777 FOREST LN C522
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75230-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-566-5880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7777 FOREST LN C522
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75230-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DERI M LEWIS
-----------------------------------------------------
Credential | MD PA
-----------------------------------------------------
Telephone | 972-566-5880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | M4289
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------