MEDICARE: LEWIS JEREMY JOHNSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	5101017835	MI
2	208800000X	Urology Physician	3622	KY
3	208800000X	Urology Physician	02006859A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1102384432	OTHER	IN	ANTHEM PTAN

General Provider Information

NPI Number	:	1295979474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEWIS JEREMY JOHNSON DO

Provider Business Mailing Address
First Line	:	210 N TILLOTSON AVE
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47304-3988
Country	:	US
Telephone Number	:	765-747-4332
Fax Number	:	765-448-7689

Provider Business Practice Location Address
First Line	:	210 N TILLOTSON AVE
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47304-3988
Country	:	US
Telephone Number	:	765-747-4332
Fax Number	:	765-448-7689

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2009
Last Update Date	:	05/14/2026

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Directions to “ LEWIS JEREMY JOHNSON DO” Practice Location

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