Provider Demographics
NPI:1487064283
Name:LEWELLYN, JAIME C (DO)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:C
Last Name:LEWELLYN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:C
Other - Last Name:HOLBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:10000 SW INNOVATION WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2111
Mailing Address - Country:US
Mailing Address - Phone:772-345-8100
Mailing Address - Fax:
Practice Address - Street 1:10000 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2111
Practice Address - Country:US
Practice Address - Phone:772-345-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3153207RC0000X, 207RI0011X
FL21719207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027984Medicaid