Basic Information
Provider Information
NPI: 1003293408
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEWIS
FirstName: MAKENZIE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1735 S PUBLIC RD
Address2:  
City: LAFAYETTE
State: CO
PostalCode: 800267093
CountryCode: US
TelephoneNumber: 0336504460
FaxNumber:  
Practice Location
Address1: 1735 S PUBLIC RD STE 100
Address2:  
City: LAFAYETTE
State: CO
PostalCode: 800267093
CountryCode: US
TelephoneNumber: 3036659310
FaxNumber: 3036653397
Other Information
ProviderEnumerationDate: 05/05/2015
LastUpdateDate: 06/03/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 06/03/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XDR0058864COY Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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