Basic Information
| Provider Information | |||||||||
| NPI: | 1093714230 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163762451 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163762451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 131715 | NY | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | 2080P0201X | 131715 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
ID Information
| ID | Type | State | Issuer | Description | 00010264202 | 01 | UNIVERA | OTHER | 00762327 | 05 | NY | MEDICAID | 0206516 | 01 | IHA | OTHER | 000500015002 | 01 | BC/BS | OTHER | 040426004096 | 01 | FIDELIS | OTHER |