Provider Demographics
NPI:1174626402
Name:LEWIS, MATTHEW DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 481
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050
Mailing Address - Country:US
Mailing Address - Phone:719-469-9220
Mailing Address - Fax:719-384-6511
Practice Address - Street 1:20817 HIGHWAY 266
Practice Address - Street 2:
Practice Address - City:ROCKY FORD
Practice Address - State:CO
Practice Address - Zip Code:81067
Practice Address - Country:US
Practice Address - Phone:719-254-3532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86951556Medicaid
BL4336536OtherDEA
BL4336536OtherDEA
CO86951556Medicaid