MEDICARE: JEFFREY LEWIS OD

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	152W00000X	Optometrist	046.010600	IL

General Provider Information

NPI Number	:	1801142351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY LEWIS OD

Provider Business Mailing Address
First Line	:	2221 W COLLEGE AVE
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-2375
Country	:	US
Telephone Number	:	309-938-4949
Fax Number	:	312-327-7621

Provider Business Practice Location Address
First Line	:	507 W TOWN CENTER BLVD
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-1248
Country	:	US
Telephone Number	:	217-531-5393
Fax Number	:	312-327-7621

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

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	08/01/2012

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