Provider Demographics
NPI:1174581300
Name:LEWIS, LEONARD A JR (DO)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:A
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 LAKE MICHIGAN DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-4520
Mailing Address - Country:US
Mailing Address - Phone:616-453-2429
Mailing Address - Fax:616-453-8340
Practice Address - Street 1:3863 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-4520
Practice Address - Country:US
Practice Address - Phone:616-453-2429
Practice Address - Fax:616-453-8340
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2675756Medicaid
MI2675756Medicaid
MI5410060Medicare ID - Type Unspecified