Provider Demographics
NPI:1710728175
Name:LEWIS, MICHAEL R
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2934 GLENWAY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45204-1752
Mailing Address - Country:US
Mailing Address - Phone:832-917-9480
Mailing Address - Fax:
Practice Address - Street 1:4900 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3916
Practice Address - Country:US
Practice Address - Phone:513-435-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005108175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist