Provider Demographics
NPI:1487817466
Name:LEWIS, CHANTAL D (MD)
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:D
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHANTAL
Other - Middle Name:D
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3122 GOLANSKY BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4267
Mailing Address - Country:US
Mailing Address - Phone:571-989-4134
Mailing Address - Fax:703-774-3939
Practice Address - Street 1:3122 GOLANSKY BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4267
Practice Address - Country:US
Practice Address - Phone:571-989-4134
Practice Address - Fax:703-774-3939
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD038499207Q00000X
MDD0069954207Q00000X
VA0101245466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine