Basic Information
| Provider Information | |||||||||
| NPI: | 1396706487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | BYRON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 252 MATLOCK RD STE 244 | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760634294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177848268 | ||||||||
| FaxNumber: | 8174778881 | ||||||||
| Practice Location | |||||||||
| Address1: | 252 MATLOCK RD STE 244 | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760634294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177848268 | ||||||||
| FaxNumber: | 8174778881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 43653-020 | WI | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.